Credit Card Authorization Contract

or fill out the form below.

To Debit My:*
Credit Card*

Discover
MasterCard
Visa
Supported Credit Cards: Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Amount To Charge*
Billing Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Do You Agree To Our Electronic Signature Terms?*
- I Agree
You consent and agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using any electronic service we offer; or in accessing or making any transactions regarding any agreement, acknowledgement, consent, terms, disclosures or conditions constitutes your signature, acceptance and agreement as if actually signed by you in writing. Further, you agree that no certification authority or other third party verification is necessary to validate your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or resulting contract between you and Afford-A-Bail Bail Bonds. You understand and agree that your e-Signature executed in conjunction with the electronic submission of your application shall be legally binding and such transaction shall be considered authorized by you.
Signature*
Defendant*
First Last
Date To Charge*
MM slash DD slash YYYY
Bondsman
First Last
Date
MM slash DD slash YYYY

Credit Card Authorization Contract