Automatic Payment Form – Personal / Corporate Accounts
Authorize Seattle Express Ride to set up recurring automatic credit card payments for transportation services.
Account Holder Information
Name of Individual or Business
*
Client Contact (if Business)
Email Address
*
example@example.com
Daytime Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address of Individual or Business
*
Effective Date
*
-
Month
-
Day
Year
Date
Payment Card Information
Type of Card
*
Visa
MasterCard
American Express
Discover
Card Number
*
Expiration Date
*
-
Month
-
Day
Year
Date
Security Code
*
Name on Card
*
Billing Address Associated with Card
*
Authorization and Signature
Authorization
Signature of Individual or Business
*
Printed Name
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: