Credit Card Authorization Form by yaohongmeiyes

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									                                                                       Contract Date: ____________________
                                                                    Defendant Name: ____________________
                                                                    Power Number(s): ____________________
CA Insurance Lic. 1838881                                            Bond Amount(s): $___________________
Ph. (877) 698-6600                                               Premium Amount(s): $___________________
Fax (805) 618-2955
Web: BailOnDemand.com




                                                  CREDIT CARD
                                                 AUTHORIZATION

Cardholder Name : ______________________________
Billing Address : ___________________________
                                         ____________________ ZIP CODE: __________
Billing Telephone #: ___________________________
Driver License:________________________ Exp. __________

Circle One:



Card Number : ______________________________                                      Exp. Date : ___________

CVV: __________                                      Total Purchase Amount : $__________________
* This is the 3-digit code on the back of the card
in the signature strip. For the American Express
card, it is the 4-digit code located on the front.                                                  Authorization Code:

Cardholder Signature: 8_________________________                                                    ___________

The above purchaser agrees to pay total purchase amount according to the card issuer agreement (Merchandise agree-
ment if credit voucher). Cardholder understands that we are not liable for any additional fees which might be imposed
by card issuer. This includes, but is not limited to, transaction fees, higher interest rates, or any other costs that may
be related to this transaction. Purchaser also understands that the premium paid is fully earned upon the arranging
and/or execution of Bail Bond. Whether or not there was an improper arrest, the bail gets reduced, or the case
is dismissed does not obligate the return or forgiveness of any portion of the premium.
                                                                                                                Initial Here

								
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