Freightliner of bridgeport

FREIGHTLINER OF ELKTON
189 Belle Hill Rd Elkton, MD 21921
PHONE# [phone]
FAX # [phone]


CREDIT AUTHORIZATION / RELEASE FORM

Authorization From: MS EXPRESS

Cardholders Name (as it appears on credit card): Nurzod Nurali
Company Name: MS EXPRESS INC
Address: 455 Bluejack lane ST, Augustine,FL 32095
Phone Number: 4402904884 Fax Number: 4402904884
Credit Card Type: (MC, Visa, Discover, Debit): VISA card
C
Please provide expiration date and 3or 4-digit security code in the space provided below
redit Card Number: 4741 6600 0247 9613
Billing address on file with Credit Card Co – if different than above:
8495 Estates Ct, Plain City, OH 43064, United States

Phone Number on file with Credit Card Co. – if different than above: 779 707 0707

Invoice Number: 50% deposit for repair Total amount charged: $1859.25

I authorize Transteck, Inc. dba Freightliner of Elkton to charge the above agreed upon service charges, plus applicable taxes to the credit card above. I agree to pay the total charges according to the card issuer agreement for services rendered and I acknowledge that I am authorized to approve above charges.
I authorize my representative, Felix Edmund to sign the credit card slip on my behalf.

CARDHOLDERS SIGNATURE: Nurzod Nurali DATE: 05.03.2023

CARDHOLDERS PRINTED NAME: Nurzod Nurali

Expiration Date: 10/26

Security Code: 797

Tear off corner upon completion of transaction