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Credit Card Authorization Form

Trip Acceptance & Debit or Credit Card Signature for ...

Trip Confirmation No.*

Please type your trip confirmation number!

Full Name*

Please type first name!

Company Name

Please type your company name!


Billing Information

Payment Type*

Please select Payment types!

Card Number*

Invalid Input, please try again!

Expiration Year

Invalid input!

Expiration Month

Invalid Input!

Please Input your credit card's security code!


Card Holder's Name*

Please type card holder name!

Address Line 1*

Please type credit card billing address!

Address Line 2

Please type credit card billing address.

City*

Please type city!

State*

Please select state!

ZIP Code*

Please type zip code!


Contact information

Phone Type
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Phone Number*

Please type your phone number!

Email*

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Other Phone Number

Please type your phone number.

Fax Number

Please type your fax number.



Clear Copy of Credit Card

Note: Your photo format should be "JPEG", "JPG", "GIF" or "PNG" and it should not be more than 3.5MB in size.

Please include a clear copy of credit card holder identification!


Clear copy of card holder's ID

Note: Your photo format should be "JPEG", "JPG", "GIF" or "PNG" and it should not be more than 3.5MB in size.

Please include a clear copy of card holders ID!


Driver's License Number*

Please type your driver's licenses number!


A minimum of 50%, Non-Refundable deposit is required.

Deposit*

Please type authorized amount!

Date of Charge*

Click on the calendar icon

Invalid input!


Optional Payments?

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First authorized amount

Please type authorized amount!

Date of charge

Click on the calendar icon

Invalid input!


Second authorized amount

Please type authorized amount!

Date of charge

Click on the calendar icon

Invalid input!


Trip confirmation No.*

Please type your Trip confirmation Number!


I agree:

Please check all the boxes above to complete your transaction!


Please type in your full name - Signature*

Please type in your full name!


Invalid Input, are you robot?


We accept debit or credit.
Credit Card Authorization Form | Colony Limo

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Colony - Limo Service Houston - Reviews
Colony - Limo Service Houston - Reviews
Colony - Limo Service Houston - Reviews

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