Payment

Card Authorization Form

One-time debit/credit card payment authorization

Sign and complete this form to authorize Emergency Towing and Recovery Inc to make a one-time charge to your debit or credit card listed.

By signing this form, you give Emergency Towing and Recovery Inc. permission to charge your account for the amount indicated on or after the indicated date. This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account.

Invoice Number

Cardholder Name

Amount ($)

Date

Billing Information

Billing Address

City

State

Zip Code

Debit / Credit Card Details

Last 4 Digits of Card

Expiration Date

CVV

I authorize the business (Emergency Towing and Recovery Inc.) to charge the Debit/Credit card indicated in this authorization form according to the terms outlined above.

This payment authorization is for the goods/services described above; for the amount indicated above only and is valid for one (1) time use only. I certify that I am an authorized user of this debit/credit card and that I will not dispute the payment with my Debit/Credit card company; so long as the transaction corresponds to the terms indicated in this form.

I agree to the terms above and authorize this one-time payment.

Electronic Signature (Type Full Name)

Date

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