Credit Card Authority To Charge printable pdf download

CREDIT CARD AUTHORITY TO CHARGE

____________________

Date

Citra Metro Manila Tollways Corporation

CMMTC, 3/F Toll Operations Bldg., Doña Soledad Ave.

Brgy. Don Bosco, Parañaque City

This is to authorize Citra Metro Manila Tollways Corporation (“CMMTC”) and its Authorized Credit Card Bank Host

(“Provider”), to charge my Credit Card for the replenishment of my AUTOSWEEP RFID Account in accordance with

the selected mode and the credit card information as provided below:

CREDIT CARD DETAILS

AUTOSWEEP RFID ACCOUNT DETAILS

: ____________________________

Card Holder’s Name

Account Name

: ______- ______- ______ - _______

: ____________________________

Credit Card No.

Account No.

: 



: ____________________________

Card Type

Email Address

MasterCard

Visa

JCB

Amex

: ____________________________

Issuing Bank

Landline No.

: ____________________________

Expiry Date

Mobile No.

(MM/YY)

Auto Replenishment Amount

Threshold Amount:

 P500

 P1,000  P2,000  P3,000  P5,000

 P500

 P1,000  P2,000  P3,000  P5,000

(Min. Amount)

(Default)

 Other Amount

P_____________

(Pls. Specify)

NOTE: An Authorization letter from the credit card holder is required (along with the photocopy of the front face of the credit card) if the credit card holder and the

AUTOSWEEP RFID account holder is not the same person/entity.



I voluntarily disclose the above information for my AUTOSWEEP RFID load replenishment.



I understand and agree that this arrangement shall be on a continuing basis unless cancelled in writing

by the undersigned or as deemed necessary by Citra Metro Manila Tollways Corporation.



I am aware that I am responsible in updating my credit card information two (2) months before my

credit card expiration to avoid discontinuance of my automatic replenishment arrangement.



I aware that any changes in my credit card information requires me to submit a new Credit Card

Authority to Charge form along with the photocopy of the front of my credit card.



I fully understand and agree that failure to debit my account due the credit card issuer’s dishonor of

my credit card for whatever reason will result to the immediate cancellation of this authorization

without prior notice.

_________________________________

PRINTED NAME & SIGNATURE

To be filled up by AUTOSWEEP RFID Account Management Group

Customer Care (Front-Office)

Customer Care (Back-Office)

Date Received

: _______________________

Date Received

: _______________________

Received & Verified by: __________________

Date Processed : _______________________

Location

: _______________________

Processed by

: _______________________

Remarks: _____________________________

______________________________________

Credit Card Authority To Charge

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