NYC State Limo

Payment authorization form

Credit Card Authorization Form      


Sign and complete this form to authorize the merchant below to make a one-time charge to your Credit Card listed below.


By signing this form,  you give us the permission to debit your account for the amount 

Indicated on or after the indicated date.


I  authorize State Transportation LLC to charge my Credit Card indicated below 

For $ on    

Goods/Services Rendered:


Billing Details

Billing Address  

City,State, Zip


Phone # 

Credit Card Information

Type of Card: 

Cardholder’s name:  

Credit Card Number:  

Expiration Date:  

Security Code:  


Front of credit card :

Back of credit card:

Your state ID or driving license (Optional):

Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Payment authorization form
lock iconUnique Document ID: d7015404272ebca8f64a58faa8d3ff8831e4c57f
Timestamp Audit
August 25, 2022 11:48 pm ESTPayment authorization form Uploaded by States Transportation LLC - IP