Credit Card Authorization Form Credit Card Information Select Your Credit Card Type : VISA MASTERCARD AMEX DISCOVER OTHERS CARD HOLDER NAME : CARD NUMBER : EXPIRATION DATE : SECURITY CODE : Billing INFORMATION COMPANY NAME : AUTHORIZE PERSON NAME : YOUR PHONE : EMAIL ADDRESS STREET ADDRESS : YOUR CITY : STATE : ZIP CODE : Attachments DRIVER LICENSE ID FRONT DRIVER LICENSE ID BACK CREDIT CARD FRONT CREDIT CARD BACK LAST FOUR DIGITS OF CREDIT CARD : AMOUNT : SIGNATURE DATE I, hereby certify that I am an authorized user of the credit card and I authorize above company to charge this card for given amount for the goods or services specified. I agree that this payment is non-refundable and will not dispute the charge with my credit card issuer as long as the transaction corresponds to the terms outlined in this agreement. I further affirm that this authorization is valid for the specified amount and any related fees incurred under the agreed terms. I acknowledge and accept that in the event of any disputes regarding the quality, delivery, or provision of the goods or services purchased, I will resolve these disputes directly with AJ Road Service Repairs, without seeking to cancel or reverse this credit card payment. By signing, I agree to the above terms and conditions. Submit Form
