Credit Card Authorization Form
Please fax back with :
1.Photo Copy of Credit Card
2. Photo Copy of Driver License
3. Fax Completed form to 201-585-2741
Customer Information:
Name _________________________________________
Street Address__________________________________
City________________________________________________
State______________ Zip________________
Phone#__________________ Fax#______________________
Credit Card Information:
Name on Card______________________________________
Card Number_______________________________________
Expiration Date_____________________________________
Circle One Visa Master card American express
CVV2 Code (3 digit code on back of Visa/Mastercard) ________
CID Code (4 digit code on front of American Express) _______
Billing Address On Credit Card____________________________
_____________________________________________
Driver License#____________________ State__________
_____________________________________________
To Whom it May Concern:
By this letter of facsimile, I am authorizing ABC towing to charge my credit card listed above for any charges incurred for services rendered.
Amount of Charges $_________________________
Authorized Signature______________________________
Print Name__________________________ Date____________