Boost Credit Card Autho Form

RECURRING CREDIT CARD AUTHORIZATION FORM

PO Box 852 I Oakwood, Ga 30566 I 770.967.2535
Type of Card
BILL TO: Cardholder's name
Card number
Expiration date (Month / Year)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Card verification/Security code
Company Name
Street
City
State/Zip
Phone number
Format: (000) 000-0000.
Email address
example@example.com
PLEASE NOTE: A 3% CREDIT CARD PROCESSING FEE WILL BE ADDED TO EACH CREDIT CARD TRANSACTION.

Boost Transport, LLC had the right to refuse service if the Credit Card is declined. This form will be stored and kept confidential within our accounting department.

I certify that I am an authorized holder and signer of the card referenced above. I agree that I will not dispute the above credit charge / debit charge through my credit card / debit card issuer or provider, so long as the transaction corresponds to the invoices and terms provided by Boost Transport, LLC.I agree that this is a periodic charge that will be made, and to terminate the recurring billing process, I must either cancel my account or arrange for an alternative method of payment. I understand that all account cancellations must be made in writing according to the requirements of Boost Transport, LLC. This form will be kept on file for one (1) year and will have to be completed again after this time.
Cardholder's signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Question or concerns, please contact our Accounting Department at accounting@boosttransport.net or call 678-997-2535 ext 1006.
Should be Empty:

RECURRING CREDIT CARD AUTHORIZATION FORM