Required Fields in Yellow
Please Enter Your Card Information
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Card Type:
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--Select Card--
Visa
MasterCard
Amex
Discover
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Card Number:
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CVV Number:
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Expiration Date:
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--Month--
January
February
March
April
May
June
July
August
September
October
November
December
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Amount Charged:
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Billing Information
As it appears on your credit card
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First Name:
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Last Name:
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Company:
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Street Address:
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City:
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State/Province:
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ZipCode:
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Country:
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Email and Phone Number
Where you wish to be contacted about your purchases. This will also serve as
your customer ID.
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Email:
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Phone Number:(xxx-xxx-xxxx)
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Defendant Details
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Defendant's First Name:
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Defendant's Last Name:
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Bond Amount:
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City/County Where Jail Is Located:
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State Where Jail Is Located:
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Please Provide Additional Information
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Comments:
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Where Did You Hear About Us?:
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By Submitting This credit card authorization form
you are also granting permission to use your credit card informations on file
for any additional charges that may arise in the future pertaining to your
obligations as an indemnitor and stated in the bond indemnity agreement for
this bail bond.You also accept and agree that all of the bond terms and
financial obligations stated in the bailbond indemnity agreement are made part
of this Credit Card Authorization Charge Form for future charges.This
authorization is cancelled only when all obligations of the bond are satisfied
and bond is discharged.Facsimile/s and/or copies are considered the same as
originals, serving as legal proof of authorization of all charges now and in
the future.
NOTE: Charges are subject to a processing fee of 3% that will be
subtracted from any refunds or returns owed, additionally a $100.00 application
fee may be applied for any cancellations.
I have Read
and Agree to all of the above terms.