The Corporate Edge
 

 Credit Card Authorization Debit Form

 
 INSTRUCTIONS:

        1) Print out the application (Fill it out before or after printing).
        2) Fax it to us at 408-988-6556.

 Note:  Please do not type beyond visible input boxes, when printing and faxing this form.

 Important: To assist us in deterring fraudulent use of credit cards, please fax an enlarged and lightened copy of the FRONT AND BACK OF YOUR CREDIT CARD AND YOUR DRIVER’S LICENSE, along with this authorization to (408) 988-6556.

Personal and Confidential

   
Contract Number:
Date of Service:
Name As It appears On The Credit Card:
Billing Address: (where the credit card bill is sent)
City:
State:
Zip Code:
Telephone: Home
Telephone: Work ext
Fax:
Others:(Please specify)
 
Credit card information
   
Check one :
Visa  M/C  AM/EXP  DIS  DINERS
Issuing Bank :
Card Number:
 
Exp Date
 
PLEASE CHARGE CREDIT CARD AS FOLLOWS
(Fill in one only please.)
 
1 /3 Deposit only: $ OR Full Amount:
I would like to establish a retail credit card account and authorize LeGrande Affaire Limousine Service, Inc. to process any charges for all future service.

             I, the undersigned, authorize LeGrande Affaire Limousine Service, Inc. to charge the above referenced credit card for transportation and related services, which may be rendered through LeGrande Affaire Limousine Service, Inc. In accordance with the terms and conditions between LeGrande Affaire Limousine Service, Inc. and the undersigned, I fully understand that all chartered reservations are non-cancelable. If I should cancel my contract for chartered service, I will forfeit 1/3 of the finalized contract amount. If I should cancel my contract chartered service within 72 hours of the date and time of service, I will forfeit the full amount of the contract. In accordance with the terms and conditions between LeGrande Affaire Limousine Service, Inc. and the undersigned, I fully understand that all airport reservations are cancelable with a minimum of 4 hours notice prior to service. Should I cancel my airport reservation within 4 hours of the date and time of service I will forfeit the full amount of contract.

 Signature: Date:
(As it appears on the credit card)

          TO PROCESS YOUR REQUEST THIS FORM MUST BE COMPLETED IN ITS ENTIRETY AND ALL COPIES MUST BE LEGIBLE.