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: __________
