CAR Collision Center LLC

7967 Twist Lane

Springfield, Va 22153

(703) 455-0181

Credit Card authorization by phone, fax, or email

I _____________________________________ authorize CAR Collision Center LLc to

Full name (as is appears on credit card)

Charge $ ___________________ on my Mastercard- Visa – Discover card.

(Please circle or underline one)

My full address is _________________________________________________________.

Street address City State Zip

This charge is for the repairs to my ___________________________________________.

Year Make Model

VIN# ______________________________________________________________________

The vehicle owner’s name is _______________________________________________

Credit card # _______________________________________ exp: ______/_________

Verification code: _____________________

This is a non-refundable charge. There is a 3% charge for the transaction if it is not swiped.

X: ___________________________________ Date: ______________________

Signature