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My firm and I hereby accept responsibility for payment of invoice(s) for services requested by me as indicated on this form. My firm and I further acknowledge that this payment is due to Premier Reporting, LLC within 30 days of the billing date on invoice(s) and is not contingent upon settlement of the case. I agree that if I have no prior credit arrangement with Premier Reporting, LLC, the services indicated above may be delivered on a Prepay basis. For your convenience, Premier Reporting, LLC accepts credit card payments using Visa, Mastercard, and American Express. If any indebtedness due and owing is not paid as agreed, the undersigned agrees to pay reasonable attorneys fees, plus all costs of collection and all other costs and expenses which may be incurred by Premier Reporting, LLC relative to collection of the indebtedness due and owing, whether suit is initiated or not.

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Mailing Address

Premier Reporting, LLC P.O. Box 186 Carlisle, PA 17013

Downtown Carlisle Office and Conference Room

8 S. Hanover Street, Suite 201 Carlisle, PA 17013 Phone: 717-249-2433

Shipping Address and Administrative Office

22 W. Mulberry Hill Rd. Carlisle, PA 17013 Phone: 717-243-9770 Fax: 717-243-0413