Escrow Bill Authorization

Valley Home Inspection will allow you to pay for your inspection at escrow for a $75.00 billing fee and if the payment is secured with a credit card. If you would like to pay for your inspection at the close of escrow this form must be completely filled before we will release the inspection report. This form authorizes us to charge your credit card for the full cost of the inspection plus the $75.00 billing fee if we do not receive payment for our services within sixty days following the inspection.

All of the following fields are required.

Inspection Information

Home Inspection Address
Date of Inspection	01 - January 02 - February 03 - March 04 - April 05 - May 06 - June 07 - July 08 - August 09 - September 10 - October 11 - November 12 - December / 123 456 789 101112 131415 161718 192021 222324 252627 282930 31 /
Inspection Price (not including $75.00 processing fee)

Escrow Information

Title Company
Escrow Officer
Escrow Officer Email
Closing Date	01 - January 02 - February 03 - March 04 - April 05 - May 06 - June 07 - July 08 - August 09 - September 10 - October 11 - November 12 - December / 123 456 789 101112 131415 161718 192021 222324 252627 282930 31 /
Escrow Officer Phone #	() -

Credit Card Information

First Name (as it appears on your credit card)
Last Name (as it appears on your credit card)
Card Type	Visa Master Card
Credit Card Number	---
Expiration Date	01 - January 02 - February 03 - March 04 - April 05 - May 06 - June 07 - July 08 - August 09 - September 10 - October 11 - November 12 - December /
Security Code
Billing Address
Billing City
Billing State
Billing Zip
Cardholder's Email Address
Cardholder's Home Phone #	() -
Cardholder's Cell Phone #	() -

By clicking "I Agree" I am authorizing Valley Home Inspection to charge my credit card for the full cost of the Home Inspection listed above plus a $75.00 billing fee if Valley Home Inspection has not received payment for our inspection services within 60 days of the date of the inspection