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Credit Card Authorization Form
This Credit Card
Authorization MUST be on file with NorthAmerican Transportation
Association before any goods or services will be rendered regardless of
your preferred method of payment. An itemized invoice will be prepared for
those companies who qualify for a credit account otherwise services must
be paid for in advance or at the time services are rendered. For your
convenience, in addition to cash or company check (no personal checks
accepted with a guarantee card), we accept the various cards listed below.
Use this form to
authorize NorthAmerican Transportation Association Inc to accept and bill
your credit card, please complete all fields, SIGN and date, and fax to
800-810-6998 or return via mail to NTA. Please PRINT clearly. INCOMPLETE
FORMS CANNOT BE PROCESSED. ALL INFORMATION will be kept on file and is
strictly confidential.
Cardholder
Name:____________________________________Signature_______________________________
Cardholder Address:
_______________________________________________________
City/St/Zipcode:
__________________________________________________________
Company Name:
_________________________________________________________
NTA Account #:
________________ NTA Invoice Number
______________________
Credit Card Number:
_____________________________________________________
Card Verification Value Code# ______________ This
number is printed on your MasterCard & Visa cards in the signature area of
the back of the card. (It is the last 3 digits AFTER the credit card
number in the signature area of the card.) On American Express, it is the
4 digit number on the front of your card either on the right or left side
of the credit card.
Expiration Date: Month/year
:_____________________________
Est Amt subject to additional taxes, S / H etc:_____________________
□
VISA □
MasterCard
□ American Express
□
Monthly □
Quarterly
□
Yearly
Deduction Date:
_________
□ One Time
Use: I hereby authorize NorthAmerican Transportation Association Inc
to charge the indicated credit card the amount indicated above. This is a
one-time charge authorization. I am NOT authorizing NTA Inc to setup my
account within a recurring billing system – rather, I prefer to pay by
check or money order on all future invoices. I understand that if I wish
NTA Inc to charge any balances to my credit card in the future, I will
need to submit another authorization form at that time or choose the
selection below.
□ Recurring
Billing: I hereby authorize NTA Inc to charge the indicated credit
card the amount indicated above on a recurring basis as shown above, as
currently applies for what I requested at the time of account sign up. I
agree that this is a periodic charge that will be made according to the
billing cycle, and that to terminate the recurring billing process I must
cancel in writing 30 days in advance, or arrange for an alternative method
of payment.
Authorization: I hereby authorize NTA Inc to
charge the indicated credit card. I agree that this is either a one time
or periodic charge that will be made as indicated above. To terminate the
recurring billing process, if selected, I must cancel in writing, and then
the account will be manually invoiced and payment must be made by check or
money order. I understand that all account cancellations must be made in
writing. I will not dispute NTA’s recurring billing with my credit card
issuer so long as the amount in question was for the service rendered
prior to my canceling my account in the manner required. I agree that if I
have any problems or questions regarding my NTA account, I will contact
NTA Inc for assistance, using the contact information located on their web
site at
www.ntassoc.com. I agree that I will not dispute any charges from NTA
Inc unless I have already attempted to rectify the situation with NTA Inc
and those attempts have failed. I authorize NTA Inc and their sponsoring
agency to run an address verification search. This verification process is
a security measure to protect me, the client, from illegal fraud against
my credit card. I guarantee and warrant that I am the legal cardholder for
this credit card, and that I am legally authorized to enter into this one
time or recurring billing agreement with NTA Inc. |
