Credit Card Authorization Form Single Transaction printable pdf download

B&B MUFFLER & AUTOMOTIVE SERVICE CENTER

3000 South Lamar Blvd. Austin, TX 78704

Phone: (512) 447-5581 Fax: (512) 447-4601

Credit Card Authorization Form Single Transaction

Please fill in the following billing information and fax it back to us at the enclosed fax phone number. For security

protection you may chose to leave the actual credit card number portion blank and can call us with your credit card

number.

Date:_____________

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.

Please fill in the following information requested:

Credit Card Type: □ MasterCard

□ Visa

□ Discover

(Note: Sorry, but American Express cards must be done in person.)

Credit Card Number: ________________________________ Expiration Date:____________

Card Code (# on back of credit card): ________________________________

Cardholder’s Name (print):

____________________________________

Cardholder’s Signature: ____________________________________

Date of Signature:

________________________

Billing Address (Address statement is received at): ________________________________

City: ____________

Zip code:_____________________

** 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.

Signature: __________________________________________

Date: _____________, 20 __

Check where applicable:

□ Please allow _______________________ 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.

- Thank you!-

Credit Card Authorization Form Single Transaction