Credit Card Authorization Form

The pertinent information is indicated below:
Account to be listed as:*
(or name as it appears on the credit card)
Credit Card Number*
Expiration Date*
MM slash DD slash YYYY
CSC (Security Number)*
Amount*
Card Type*
- Amex
- Visa
- Master Card
- Diners
- Discover
Billing Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Full Name*
Email*
I hereby authorize my signature to be on file with Paris Limousine Service for the purpose of receiving payments of having the charges for the service I receive / put on my credit card.
Card Holder's Signature*
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

The pertinent information is indicated below: