Credit Card Authorization Form Single Transaction

PHONE: 512-447-5581

FAX: 512-447-4601

Please fill in the following billing information in the electronically active fields. For your protection we do not accept complete credit card numbers online. Please call us at 512-447-5581 to provide the outstanding card number information.

Phone*
Repair Order #
Repair Order Total
Cardholder acknowledges the purchase of goods and/or services in the amount of the Repair Order Total shown above and agrees to perform the obligations set forth in the Cardholder’s agreement.
Credit Card Type*
(Note: Sorry, but American Express cards must be done in person.)
- MasterCard
- Visa
- Discover
LAST FOUR DIGITS of credit card number*
Please do not enter more than the last 4 digits of the card number.
Credit Card Expiration Date*
Security code from back of your card.*
Cardholder's Name*
First Last
Cardholder's Signature*
Use your mouse, or your finger or stylus on a touch screen, to sign your name in the area below.
Date of Signature*
MM slash DD slash YYYY
Billing Address (where statement is received)
Street Address City State ZIP Code
Final Repair Order Authorization Signature and Acknowledgement By Owner or Authorized Agent:*
Use your mouse, or your finger or stylus on a touch screen, to sign your name in the area below.
Date of Signature*
MM slash DD slash YYYY
** NOTICE PURSUANT TO SECTION 70.001 TEXAS PROPERY CODE ** I am the person or agent acting on behalf of the person who is obligated to pay for the authorized repairs or services rendered to the motor vehicle identified by the Repair Order contract number herein. I understand that this vehicle is subject to repossession in accordance with Section 9.609 Texas Business & Commerce Code if a written order for payment for repairs or services rendered has been stopped, dishonored because of insufficient funds, no funds or because the drawer or maker of the order has no account of the account on which it is drawn has been closed.
Check where applicable:
- Please allow a person I designate to pick up my vehicle.
- Customer will be picking up vehicle after hours.
- Vehicle to be locked with keys and paperwork inside vehicle
- Vehicle to be left unlocked with keys and paperwork inside vehicle.
Person authorized to pick up vehicle.
Your email address*
For Security:

Credit Card Authorization Form Single Transaction

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