CC Onetime - Drive Whip

CC Authorization Form - OneTime

ONE-TIME CREDIT CARD AUTHORIZATION

By signing this form, you permit us to debit your credit card in the amount listed below as indicated in your membership agreement. The first payment will debit from the credit card listed below eight days from the date on the form and continuously every seven days after that. This form also authorizes any additional debits due to traffic violations, tolls, vehicle damage, and/or non-payment.

Customer Name:(Required)

First Last

Customer ID:(Required)

This Authorization is entered into between the above-named Customer (“Customer”) and DriveWhip, Inc. (“DriveWhip”).

By signing below, Customer authorizes DriveWhip to charge the payment method provided for a transaction related to the Customer’s account, membership, or outstanding balance.

Customer understands that the charge may relate to amounts owed under the Vehicle Membership Agreement or other account-related obligations.

Customer certifies that they are the authorized cardholder or have express authorization from the cardholder to use the payment method provided. Customer understands that providing false authorization may constitute fraud and may result in civil and/or criminal liability.

All payment information is processed securely through DriveWhip’s payment processor.

Billing Information(Required)

Billing Address City State Zip

Phone Number:(Required)

Email Address:(Required)

Payment Method

Cardholder Name (if different):(Required)

Card Type:(Required)

VISA

MasterCard

AMEX

Discover

Last Four Digits of Card:(Required)

Expiration Date:(Required)

mmyy

Customer Signature:(Required)

Printed Name:(Required)

Date Signed(Required)

RowID(Required)