Fill and Sign the Fax Express Order Formpdf

S:\FormsLib\Civil Bureau\Civ Fam Intake & Customer Svc\Customer Service\Fax Express Order Form Revised 02/08/2002 The Fax Express Charles Bacarisse, Harris County District Clerk Civil Public Service Department Fax Number 755-8974 To Be Completed By The Customer (Please Print): CAUSE NUMBER: __________________________________ STYLE: __________________________________________ VS. ____________________________________________ NOTE: REQUEST BEING PAID BY CREDIT CARD MUST BE PICKED UP AT OUR WILL-CALL WINDOW WITHIN 30 DAYS FROM REQUEST. YOU MAY REQUEST NON-CERTIFIED COPIES TO BE RETURNED TO YOU VIA FAX. Need Copy Of (Please Check): DECREE/JUDGMENT DATE OF DECREE/JUDGMENT: ________________ NUMBER OF COPIES: ________ ORDER DATE OF ORDER: ___________________________ NUMBER OF COPIES: ________ Copies should be: ( ) CERTIFIED or ( ) UNCERTIFIED PLEASE SPECIFY TYPE OF DELIVERY: ( ) Mail ( ) Return Via Fax (Uncertified Only) ( ) Will Call Window (Pick-up) CUSTOMER'S NAME (Please Print): _______________________________________________________________________ ADDRESS: ___________________________________________________________________________________________ CUSTOMER'S PHONE NUMBER: _________________________ CUSTOMER'S FAX NUMBER:______________________ I hereby authorize the District Clerk to charge to my credit card for payment of the services requested above: CREDIT CARD TYPE: __________________________________________________________________________ NAME PRINTED ON CREDIT CARD: ______________________________________________________________ CREDIT CARD NUMBER: ________________________________ DATE OF EXPIRATION: _______________ AUTHORIZED SIGNATURE: ____________________________________________________________________ CREDIT CARDHOLDER ADDRESS: ______________________________________________________________ CREDIT CARDHOLDER CONTACT NUMBER: _____________________________________________________ COPY OR COPIES RECEIVED BY: ________________________________________________________________________ FOR DISTRICT CLERK'S OFFICE USE ONLY COURT: ______________________________________________ TOTAL NUMBER PAGES/SCREENS: _________________________ ORDER TAKEN BY: ____________________________________ DATE: _________________________________________________ NUMBER OF SCREENS PRINTED/VERIFIED BY: _____________________________________________________________________________ TRANSACTION NO: ____________________________________ RECEIPT NO: ____________________________________________