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 States Transportation LLC to charge my Credit Card indicated below 

For $ on    



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:

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Signature Certificate
Document name: Payment authorization form
lock iconUnique Document ID: 45b9810bcc84667d542c2731bfa99a21180e9e88
Timestamp Audit
08/25/2022 11:48 pm EDTPayment authorization form Uploaded by States Transportation LLC - IP