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Payment Authorization

Transmission Depot

9538 State Road 52

Hudson, Fl 34669

727-868-9462

TEXT PHOTO COPY TO: 727-804-6400

FAX: 727-863-9681

Email: misty@transdepot.net

One Time Credit Card Payment Authorization Form

 

Sign and complete this form to authorize TRANSMISSION DEPOT to make a one time debit to your credit card listed below. 

 

By signing this form you give us permission to debit 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.

 

 

Please complete the information below:

 

 

I ____________________________ authorize TRANSMISSION DEPOT to charge my credit card                            

                    (full name)

account indicated below for _____________  on or after ___________________.  This payment is for

                                                        (amount)                                               (date)

 

_____________________________________.

               (description of goods/services)

 

 

                                                

Billing Address   ____________________________                Phone#            ________________________

City, State, Zip ____________________________                 Email                            ________________________       

     

 Account Type:   Visa           MasterCard          AMEX       Discover           


Cardholder Name 
_________________________________________________

Account Number   _____________________________________________

Expiration Date     ____________ 

CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX) ______    

SIGNATURE                                                                         DATE                                 

 

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 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.

PLACE ID HERE

PHOTO COPY OF ID:               

 

 

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