Secure Link

This page is designed for the purpose of having our clients, when requested, send us their credit card information securely. The client that is requested to fill in the information below will not have their credit card charged online, all credit cards will be charged off-line after the services have been offered. Please fill in all fields and accept all terms and conditions found at the bottom of the page.

CREDIT CARD AUTHORIZATION FORM

Please fill out our Creditt Card Authorization form below:

    CREDIT CARD HOLDER INFORMATION

    NAME ON CREDIT CARD *

    TYPE OF CREDIT CARD *

    VISAMCAMEXDISCOVEROTHER

    CARD NUMBER *

    EXP. DATE *

    CVV# *

    BILLING ADDRESS *

    CITY *

    STATE/PROVINCE *

    ZIP/POSTAL CODE *

    PHONE *

    FAX NUMBER

    OTHER PHONE

     

    CC Photo

    FRONT VIEW

    (Format Types Accepted: .jpg, .gif, .png, .pdf | Maximum Size File: 5MB)

    BACK VIEW

    (Format Types Accepted: .jpg, .gif, .png, .pdf | Maximum Size File: 5MB)

     

    AUTHORIZED USER OF CREDIT CARD

    NAME *

    COMPANY, if applicable

    PHONE NUMBER *

    EMAIL ADDRESS  *

    OTHER PHONE NUMBER

    RELATION TO C. C. OWNER *

    TYPE OF CHARGES/SERVICES *

    PLACE OF CHARGES

    DATE/S OF CHARGES/SERVICES

     

    AUTHORIZATION OF CARD USE

    I certify that I am the authorized holder and signer of the credit card reference above. I certify that all information above is complete and accurate.

    I hereby authorize collection of payment by BLACK CAR LIMOUSINE for all charges related to services as indicated above.