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| Please print this page fill out all the inforamtion and fax it to our office along with the signed agreement. 703.437.8043 or send to 13012 Elm Tree Court Herndon, VA 20171 There are two payment options available to you. We accept credit card and visa check cards. Payment Type: Billing Address __________________________________________________________________________________ City __________________________________________________________________________________ State __________________________________________________________________________________ Zip __________________________________________________________________________________ Card Number __________________________________________________________________________________ Experation .Date __________________________________________________________________________________ Authorization Signature Print Name __________________________________________________________________________________ Sign __________________________________________________________________________________ Date __________________________________________________________________________________ By signing above you are acknowledging that you have read and understand the terms of this agreement. You herby authorize NanniNanny, LLC to charge your credit card in the amount of $300 to begin a caregiver search. Upon hiring a caregiver referred by NanniNanny, LLC, you are additionally authorizing NanniNanny, LLC to charge your credit card for a final payment of the remaining balance of the placement fee. |
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| Copyright NanniNanny, LLC 2002 |
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