Credit Card Authorization Form

DATE:

I

give EXPRESS BAIL BONDING COMPANY permission to charge my credit/debit card in the amount of $

(2%) surcharge added for Credit Card transactions) for the bail release and services for

CHECK CARD TYPE:

Card Number:

Expiration Date:
/

Security Code:

Driv Lic #:

State:

EXP:

Name As Appears On Card:

Billing Address:

City:

State:

Zip:

Card Holder Phone Number:
()

Charge Authorized Amount: $

Card Holder Signature:

Card Holder Name (Print):

** INITIAL:

** CREDIT CARD WILL BE CHARGED THE FUILL AMOUNT OF THE BOND IF THE CASE IS FORFEITED AND JUDGEMENT IS RENDERED AGAINST THE DEFENDANT.