Credit Card Authorization Form | US Truck and Trailer Mobile Repair

Date*

Cardholder's First Name*

Cardholder's Last Name*

Cardholder's Phone Number*

Cardholder's Email Address*

Credit Card Type*

VISA

MASTERCARD

DISCOVER

AMERICAN EXPRESS

Credit Card Number*

Credit Card Expiration Date*

Credit Card CVV*

Amount To Be Charged*

Billing Address*

Description of Services*

Contract Agreement*

By checking this box, I agree that I have received all the services I ordered. The services were to my satisfaction and I will not dispute these charges for any reason. I agree not to initiate a chargeback proceeding with my credit card Company by US Truck and Trailer Mobile Repair on the credit card above, and understand that any chargebacks will constitute a breach of contract. I agree to waive any chargeback rights I may have.

Authorization to Process Credit Card*

By checking this box, I authorize US Truck and Trailer Mobile Repair 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.