Cal-Nevada Credit Card Authorization Form

Credit Card Authorization
Reference #
Card Type:*

VISAMastercardDiscover
Cardholder Name (As it appears on the Card)*

First NameLast Name
Person Authorized to Approve Work / Changes

First NameLast Name
Phone Number*
Please enter a valid phone number.
Credit Card Number*
Expiration Date*
CVC*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Front of Credit Card

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Back of Credit Card

Cancelof
Estimated Charges $
Cardholders Driver’s License Number*
Please attach a clear picture of your Driver’s License for identity verification.
Driver’s License State*
Upload Driver's License Photo*

Cancelof
I certify that the information above is accurate and complete and hereby authorize the collection of payment via the above credit card for the services performed. I understand and agree to the following: Estimated charges may vary depending upon the actual conditions encountered. Should additional work be required that exceeds the estimate above, Cal-Nevada Towing (company) will obtain authorization from either the cardholder, or the person indicated above as "PERSON AUTHORIZED TO APPROVE WORK/CHARGES" prior to completing additional chargeable work. The later may indicate their approval via their signature on the Cal-Nevada Towing invoice. If the "Estimated Charges" field is left blank, I agree to pay the actual charges invoiced by company. I understand the company is entitled to compensation for work performed and equipment utilized. I authorize company to charge for travel and work actually performed if the service cannot be completed due to materially inaccurate or incomplete information being provided to company. Hourly charges begin accruing when operator(s) depart base. Cancellation of service later than 15 minutes past operator departure will result in charges for their actual port to port travel time (time spent traveling from base and back).
Cardholder Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: