Authorization Of Credit Card Use For Association Related Fees

Date:  ______________________

President & Chief Operating Officer

North Shore-Barrington Association of REALTORS®

This is to serve notice to the North Shore-Barrington Association of REALTORS® granting permission from

Agent Name __________________________________________________________________

Agent Number _________________________________________________________________

Holder of the (circle one) VISA, MASTER CARD or AMERICAN EXPRESS identified below

CARD NUMBER _________________________________  Expiration Date __________________

RESIDENT ADDRESS ____________________________________________________________

Street City Zip Code

I authorize the North Shore-Barrington Association of REALTORS® to pay the balance due on my

(Please indicate your selections by checking the appropriate lines)

____Multiple Listing Service account each month

____Board charges each month

____Yearly Board, State and National dues

OR, ONE TIME ONLY

____Multiple Listing Service account amount of ______________

____Board charges account amount ______________

____Yearly Board, State and National dues amount _________________

The Association has my permission to charge that amount to this card after the 15^th of each month and that total is NON-REFUNDABLE. I further acknowledge that I will bear all expenses related to charge back items should this association bill be questioned at some point beyond the 15^th of the month.

SIGNATURE _____________________________________________________________________

(Print Name) ______________________________________________________________________

DATED THIS DAY OF _____________________________, 200____________________________