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

Confirmation#:

Billing Details

Billing Address

City,State, Zip

Email

Phone #

Type of Card:

Cardholder’s name:

Credit Card Number:

Expiration Date:

Security Code:

Front of credit card :

Credit card (Front)

Back of credit card:

Back

Your state ID or driving license (Optional):

ID/License (Optional)

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

08/25/2022 11:48 pm EDT

Payment authorization form Uploaded by States Transportation LLC - Nycstatelimo@gmail.com IP 116.206.66.226