NLB/ Global Construction

Industry Support
National Lien and Bond Claim Systems
A Division of Network *50, Inc.
440 Central Avenue
Highland Park, Il 60035
P: 800.432.7799
F: 847.432.8950
NLB PROJECT REVIEW
CREDIT CARD AUTHORIZATION
Emalfarb, Swan & Bain acting as General Counsel for National Lien & Bond Claim Systems requires
a credit card authorization for the initial review of files and/or other agreed to subsequent flat fee charges
such as a notice or lien claim. There is a $150.00 file review fee per file. Please fill out the form below and
return it to National Lien & Bond via fax at 847-432-8950. Please contact Marlene Schwan for inquires at
1-800-432-7799 x111.

Please Print Your File # as it appears on ESB invoice: ______________

________________________________________________________________________
Name
________________________________________________________________________
Title
________________________________________________________________________
Organization URL
________________________________________________________________________
Address
______________________________________________________________________
City State/Province Country ZIP/Postal Code

________________________________________________________________________
Phone Fax e-mail

Initial Claim Review Fee: $150.00 per claim

Credit Card Authorization:

__________________________________________________________________________________________
Name on Card

________________________________________________________________________
Billing Address

________________________________________________________________________
City State/Province Country ZIP/Postal Code

Visa MasterCard American Express

Credit Card #: ______________________________________ Exp. Date____/_____ 3 Digit SVC code:_______

(located on the back of card)

Signature: ______________________________________________________________
(Signature required to process payment)

By signing this form I authorize the sum of this transaction