Fort Lauderdale Airport Jet Center 1100
Lee Wagener Blvd. Suite 326 Fort Lauderdale,
FL 33315
GENERAL CREDIT CARD AUTHORIZATION FORM
Phone: 561-843-5111
561-305-9222
Fax: 954-757-7415
561-305-9222
Fax: 954-757-7415
Middle:
Auth member
first name:
first name:
Last name:
Billing city:
Billing street address:
Billing state:
Billing zip:
Contact name:
Phone #
Ext
Credit card details
Type:
Card #
Exp:
Sec digits
Place a copy of front and back of credit card in the space below
CARD FRONT
CARD BACK
Email:
or scan front and back of card and send it by E-mail
I, the undersigned, hereby authorize Palm Beach Limo to automatically deduct payment from the credit card listed above to cover all charges
in behalf of _______________________________________________________________________ (passenger's name).
· A $3.00 or 3.50 % (whatever is higher) credit card processing surcharge will be added to total fare amount as disclosed on confirmation.
Card member signature: __________________________________________ Date: _______________
Please complete, print, sign and fax/mail it to Executive Transportation using the information above.
in behalf of _______________________________________________________________________ (passenger's name).
· A $3.00 or 3.50 % (whatever is higher) credit card processing surcharge will be added to total fare amount as disclosed on confirmation.
Card member signature: __________________________________________ Date: _______________
Please complete, print, sign and fax/mail it to Executive Transportation using the information above.
Palm Beach Limo