6280 Seven Pines Drive
6280 Seven Pines Drive
West Carrollton, OH 45449
(937) 434-9004
(937) 438 6825 fax
CREDIT CARD AUTHORIZATION FORM
We appreciate the decision you have made to secure transportation with Emerald Limousine Service. Since you have chosen the option of utilizing your Visa, MasterCard, Discover or American Express to pay for your orders, please complete the information below.
The purpose of this form is that due to banking regulations and as a result of banks and individuals suffering extensive losses on credit card transactions, our bank has requested that any Emerald Limousine Service customer who wishes to use a credit card to pay for orders must have a signature in our files, authorizing us to accept their credit card telephone orders. This request will help to protect you and your credit card account from any credit card misappropriations. Please know that it is only necessary to complete this form once for all of your credit card orders with Emerald Limousine Service.
So that we may comply with our bank’s request, we are asking that you complete this form, sign it at the bottom, and return this to our office. We are happy to accept a fax or mailed return copy of this form at (937) 438 6825.
If you plan to use more than one credit card to pay for your orders, please copy this form, complete the second copy, and return it at the same time as you return this form.
I authorize Emerald Limousine Service to accept telephone, fax and mail orders in which I will use my credit card as payment for the amount I specify in those orders to Emerald Limousine Service. I have completed the below Credit Card Authorization Form, and I understand that any order is not valid until accepted by Emerald Limousine Service, who reserves the right to refuse any purchase orders, either written or verbal. I understand that Emerald Limousine Service makes no warranties other than those set forth in this agreement or created by law in the state in which I reside.
NOTE: For any challenges with mailed in or telephoned in credit card orders, an attempt to reprocess the order will be made once each day for a period of not more than three (3) consecutive business days, using that same credit card number. These challenges may include: declined card, invalid card, illegible or incomplete card number and/or expiration date, etc. Upon the third and final failed attempt to process this order, the order will be deleted from Emerald Limousine Service’s open order status and the reservation will no longer be guaranteed. Although this Credit Card Authorization Form is on file at Emerald Limousine Service, Emerald Limousine Service reserves the right to request additional information on each individual order.
COMPANY NAME _____________________________________________________________________
VISA/MasterCard/AMEXAccountNumber______________________________________________
EXP DATE _____/_____
CVV Code (last group of 3 or 4 numbers on back of card)__________________
CARDHOLDER’S NAME_________________________________________________________________
CARDHOLDER BILLING ADDRESS (must match address on file with credit card company)
Street Address
_________________________________________________
City: _____________________________ State: ____________ ZIP:
_____________
DAY
TEL # (______)
_________________ EVE TEL # (______) _________________
FAX # (______) _______________
CARDHOLDER SIGNATURE
____________________________________________________
DATE ________________
®® NOTE: You may return this form to Emerald Limousine Service via Fax or mail. ¬¬