Payment authorization form

Credit Card Authorization Form      


Sign and complete this form to authorize the merchant below to make a one-time charge to your Credit Card listed below.


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

Indicated on or after the indicated date.


I  authorize States Limo to charge my Credit Card indicated below 

For $ on    



Billing Details

Billing Address  

City,State, Zip


Phone # 

Credit Card Information

Type of Card: 

Cardholder’s name:  

Credit Card Number:  

Expiration Date:

Security Code:  


Front of credit card :

Back of credit card:

Your state ID or driving license (Optional):

Leave this empty:

Signature arrow sign here

Signed by States Limo
Signed On: February 18, 2024

Signature Certificate
Document name: Payment authorization form
lock iconUnique Document ID: 0da02778d882c310c37f0d3fa52d814755c97b4c
Timestamp Audit
February 18, 2024 6:28 pm EDTPayment authorization form Uploaded by States Limo - IP