Credit Card Authorization

* = Required Fields
Show | PO# | Job Name:
*Company Name:
*Credit Card First Name:
*Last Name:
*Billing Contact Email:
*Billing Address:
*Billing City:
*Billing State:
*Billing Zip:
*Phone #:
Fax #:
*Credit Card Number:
*Expire on:
(The CID no. is the value printed on the signature panel on the back of the card, immediately following the credit card account number.)
Keep Card on File:

By entering your credit card information:

a. You are stating that you are an authorized user of the credit card and that the associated information entered ( account holder name, account number, billing address, etc.) is accurate.

b. You authorize Quixote to charge the credit card for any payment for which you may become liable for including but not limited to, the full amount of any service which remains unpaid after 60 days after the date of the invoice.

c. You agree that in the event the credit card becomes invalid, you will provide a new valid credit card upon request, to be charged for the payment of any outstanding balances owed.

d. You further agree that Quixote will run a $1.00 authorization to validate card information. This charge will not settle to your account.

Cardholder’s Agreement: