Credit Card Authorization Form

CREDIT CARD PAYMENT AUTHORIZATION AGREEMENT
The cardholder hereby authorizes On Time Messenger Service, Inc. for its own account to initiate invoicing and charges for transactions to the cardholders credit card account listed below. This authority shall extend to include signature on file transactions. The cardholder acknowledges receipt of all goods and services charged through this agreement.
Date
MM slash DD slash YYYY
Amount to be charged USD
Pickup Company
Pickup Contact Name
Delivery Company
Delivery Contact Name
Pickup Address
Street Address Address Line 2 City State ZIP Code
Delivery Address
Street Address Address Line 2 City State ZIP Code
Phone at Pickup Location*
Phone at Delivery Location*
Credit Card Information
Card Type
- Visa
- MC
- AMEX
- DISCOVERY
Cardholders Name
Credit Card Number
Expiration Date
Security Code
Billing Address
City
State
Zip
Email
Signature
CAPTCHA

CREDIT CARD PAYMENT AUTHORIZATION AGREEMENT