FILL OUT THIS FORM AND FAX IT TO NYLIENS.COM: 516-334-3000
I hereby authorize NYLIENS LLC to prepare a Satisfaction of Mechanic's Lien for a Lien that is filed against:
Owner/Contractor Liened: _____________________________________
Property Address: ___________________________________________
and I hereby authorize NYLIENS LLC and/or its affiliates to charge the sum of $150.00 to my credit card listed below.
__________________________________________Signature__________________________________________Name__________________________________________Company Name__________________________________________Dated__________________________________________
Phone Number
__________________________________________
eMail Address
PAYMENT BY CREDIT CARD
CARD TYPE (check one): [ ] VISA, [ ] MASTER CARD, [ ] AMERICAN EXPRESS
CARD NUMBER _____________________________________________
EXPIRATION DATE (month/year): ________
CREDIT CARD VERIFICATION NUMBER: ________
(for Visa and Mastercard - this is a 3 digit number located on the reverse side of your card, for American Express - this is a 4 digit number located on the front side of your card)
NAME ON CARD: _____________________________________________
BILLING ADDRESS: ______________________________________________
CITY: ___________________________ STATE: ______ ZIP CODE: _____________
I HEREBY AUTHORIZE NYLIENS LLC OR ITS AFFILIATES TO CHARGE THE ABOVE CREDIT CARD.
[SIGN HERE]______________________________________________ DATE: ________