A Bail Away Bonding Company Inc.

Credit Card Authorization Form

Amount Being Charged is 10% of Total Bond Amount, Plus State Tax, Plus Origination Fee, Plus a 5% Credit Card Processing Fee.

(Example $1000 Bond =$100 + $12 + $25 + $6.85 = $143.85)

Date: ____/______/________

Defendant Name: ____________________________________

Bond Amount: $_______________

Name of Card Holder: ___________________________________

Mailing Address: ____________________________________

____________________________________

____________________________________

Phone No: ____________________________________

Credit Card No: ____________________________________

Exp. Date: _______/________/________

CVV No: ________________________

(3 digit number on back of card)

Amount Charged: ___________________________________$_______________

Card Type: Visa________MC_________Discover________

Authorization Number: __________________

Card Holder Signature: ______________________________