123 Corporate Transportation LOGO
123 Corporate Transportation
P.O. Box 612465
Miami, FL 33261

(877) 691-2374
Fax (917) 591-8290

Credit Card Authorization Form

Note: Please complete online, print, sign and either fax or scan & eMail.
Card holder's first name:   Middle name: Last name:
Company Name:    
Billing street address:    
Billing city: Billing State: Billing zip:
Contact name: Phone #: Extension:

Credit Card Details

Card type:   Card #: Exp date: Sec Code (CVV):
  Choose CC authorization type  

I, the undersigned, hereby authorize 123 Corporate Transportation to automatically
deduct payment from the credit card listed above to cover all charges as follows:
a) Charges incurred in relation with my reservation(s) # in behalf of (passenger's name).

b) Keep on-file to satisfy charges incurred and billed to our corporate account:
Legal company name:    D/B/A
Card member signature: __________________________________________  Date: _______________