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 NYC State Limo to charge my Credit Card indicated below 

For $ on    

Confirmation#:

 

Billing Details

Billing Address  

City,State, Zip

Email

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: 6e0925b860fef4b2d43f8deac774c54d70148cda
Timestamp Audit
08/25/2022 11:48 PM ESTPayment authorization form Uploaded by States Transportation LLC - Nycstatelimo@gmail.com IP 103.75.245.174