Payment - Zip Van Lines

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CREDIT CARD AUTHORIZATION FORM

"*" indicates required fields

Step 1 of 2

50%

Job Number*

Phone Number*

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Price*

Credit Card Information*

Discover

MasterCard

Visa

Supported Credit Cards: Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

Credit Card Authorization*

Yes, I Agree

By checking this box, I hereby authorize Zip Van Lines, to process payment/deposit by the payment the method selected above, relating to services to the Customer named above on this designated credit card

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Zip Van Lines

USDOT#: 4013353
MC#: 1511732