Credit Card Authorization

from Tigran Trucking Inc for the

Invoice #

—

Amount

$—

TIGRAN TRUCKING INC

3237 BORDENTOWN AVE
PARLIN, NJ, 08859
734-414-9004

One Time Credit Card Payment Authorization Form

"Sign and complete this form to authorize TIGRAN TRUCKING INC 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."

*****3% service fee for Visa/MasterCard ******
3.5% service fee for Visa/MasterCard For payments through online POS terminal

WE DO NOT ACCEPT PAYMENT WITH AMERICAN EXPRESS AND DISCOVERY

Please complete the information below:

I authorize TIGRAN TRUCKING INC to charge my credit card

account indicated below for $ on or after Date

This payment is for TRUCK/TRAILER REPAIR

Billing Address:

City, State, Zip:

Phone# (optional):

Card Type:

Cardholder Name:

Card Number:

Expiration Date:

CVV/CVC:

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.