Credit Card Authorization
I hereby authorize my signature to be on file with Chivalry Limousine LLC for the purpose of charging limousine service on my credit card. I am also aware of the rates to be charged for such services. I authorize the respective credit card company to accept this form in lieu of my signature appearing on the individual credit card receipt for services performed.
Credit Card Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Exp. Date: _ _ / _ _ Security Code: _ _ _ _
Credit Card Type : Amex____ Visa____ MC____ DISC.____
Cardholder name: _____________________________________________________________________________
CC Billing address: _____________________________________________________________________________
_____________________________________________________________________________
Passenger Name & Address if different then above: __________________________________________________
- People allowed ordering transportation
Authorized Caller 1:______________________________ Title_______________ Contact #_________________
E-Mail Address : _________________________________________________Fax#______________________
Authorized Caller 2:______________________________Title________________Contact#__________________
E-mail Address : __________________________________________________Fax#_____________________
- E-mail address:___________________________________________Fax#_______________________
We will E-mail or Fax confirmation of all calls.
Home Phone#_____________________________________Work Phone#_________________________________
Cell Phone#_______________________________________
In addition, please photocopy and return fax with this form, a copy of credit card, and a copy of the cardholders’ drivers’ license.
PLEASE CHECK A MARK ON THE LINE IF THIS IS FOR A ONETIME USE ONLY
Cardholders name (Print) Cardholders Signature
___________________________ ____________________________
