Credit Card Payment Authorization

One (1) Time Credit Card Payment Authorization

"*" indicates required fields

Sign and complete this form to authorize East Coast Towing Inc to make a one-time charge to your credit card listed below.

By signing this form, you give us permission to debit your account for the amount for 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.

Cardholder’s Full Name*

Amount*

Date*

This payment is for*

(Description of Goods/Services)

Billing Address*

Street Address Address Line 2 City State ZIP Code

Card Details*

Visa

MasterCard

Discover

American Express

Cardholder Name*

Account/CC Number*

Expiration Date*

Zip Code*

I authorize the above named business to charge the 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 credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

SIGNATURE*

DATE*

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.