Credit Card Information Worksheet
Complete the below information to allow CSX to process your credit card payment:
Terminal Location: _ ______________________________________________
(Please Specify)
Card Number: Expiration Date: Name on Card:
______________________________________________ ______________________________________________ ______________________________________________
Card Type
Visa MasterCard American Express
Cardholder’s Billing Address:
_____________________________________________________________
(Number and Street)
_____________________________________________________________
(City) (State) (Zip)
Company Name: _____________________________ Amount of Transaction: _________________________ Storage Paid Through: _________________________
(Date)
Service Provided: Container Number:
LIFT
________________________
Cardholder’s Authorized Name:
__________________________________
Phone#: ________________ Fax#: __________________
Cardholder’s Authorized Signature:
_______________________________
Date:___________________
Submitted by: ____________________________________________________________________________
(Please Print)
Upon Completion: Fax to 904-245-2184
Authorization Number: ___________________________
(Completed by CSX)
CREDIT CARDS ARE PROCESSED, MONDAY THROUGH FRIDAY, BETWEEN THE HOURS OF 7:00 AM AND 4:00 PM EST
Transactions receipts will be returned to the fax number provided. Please allow 30 minutes processing time. For a complete listing of CSX ramps and contact information, please visit www.csxi.com, click on Customer>Customer Tools>Plan>Terminal Listing
Please note: This form can not be used to process payments for storage charges, Storage Charges MUST be paid by Credit Card Payment via ShipCSX.com
08-01-2008