Credit Card Authorization form

Credit Card Authorization Form

PLEASE PRINT OUT AND COMPLETE THIS AUTHORIZATION AND RETURN TO US.

All information will remain confidential.
Cardholder Name
Expiration Date

MonthDayYear
Date
Card Identification Number (last 3 digits located on the back of the credit card):

Amount to Charge: as per valid agreement between Cardholder and Select Dispatch Services LLC.

I authorize Select Dispatch Services LLC to charge the agreed amount listed above to my credit card provided herein. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement.

Cardholder - Print Name, Sign and Date Below:
Signed

Clear
Print Name
Dated

MonthDayYear
Date
226 Meadow Path Dr, San Antonio TX 87227 Phone 845-269-9778 www.selectdsps.com
Should be Empty: