Authorization to Use Credit Card Form
WTA Services,
Inc. Permit Dept.
AUTHORIZATION TO USE CREDIT CARD
WTA Services, Inc is
authorized to use the following credit card issued to the undersigned:
Describe card and
Issuer:_______________________________________________________________________
Card # Expiration
Date:_________________________________________________________________________
V-Code #
________________________ (Last 3 digits after card number on back of
card.)
To pay for services
furnished by WTA Services at our request on the following conditions:
1. Person authorized
to order services on behalf of the undersigned are:
Name:_________________________________
Address:_____________________________________________
Social
Sec.#:_______________________________Driver License
#:_____________________________________
2. The credit card
may be used only by individuals designated by WTA Services who shall be employees of either
WTA Services or Washington Trucking Associations.
3. Request for
services may be made by telephone, telegram, facsimile, letter or in person.
4. The credit card
shall only be used to pay for charges for issuance of DOT/DOL permits.
5. Credit card
charges are 2.75% of permit and fax cost; $1 minimum per handling fee.
6. $2 fax fee in
state and toll-free; $5 fax fee out of state.
The undersigned
guarantees payment of all charges, and understands that charges not paid within thirty (30) days by
credit card use or otherwise shall bear interest at the rate
of twelve percent (12%) per annum from due date until paid.
The undersigned will give immediate
notice to WTA Services if the credit card is canceled or lost and agrees to
indemnify WTA
Services against any loss sustained through failure of credit card issuer to make payment.
Dated at
_________________________,__________ this day ________of ______________________, 200_____ .
City
State
Month
__________________________________________
___________________________________________
Company Name - Type
or
Print
Authorized Signature
__________________________________________
___________________________________________
Mailing
Address
Phone #
__________________________________________
___________________________________________
City/State/Zip
Fax #
PLEASE FAX BACK WITH A PHOTO COPY OF
ACTUAL VISA/MC CARD.
(253) 838-1650
1-800-732-9019 Fax (253) 838-1699 930 S. 336th
Street, Ste B Federal Way, WA 98003