Member first name:______________________________________
Last Name____________________________________________
Address where you receive your credit card bill.
Street:_______________________________________________
Billing city: ___________________________________________
State _________________________Zip Code_________________
Phone___________________ Cell __________________ Work ______________
Circle One: Visa ———– MasterCard ———- Amex———- Discover
Credit Card #_____________________________________Expiration Date: __________
$ AUTHORIZATION AMOUNT $_____________________________________________
Place a copy of front and back of credit card in the space below along with your picture identification (i.e your Driver License) and Fax Form to 972-840-1280. I, the undersigned, hereby authorize Angel Limos. Dallas TX to automatically deduct payment from the credit card listed above to cover all charges incurred in relation with my transportation service on behalf of ________________________________ (passenger’s name).
Card member signature: ____________________________________ Date: __________