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City Cab
1259 N Commercial St.
Aransas Pass, TX 78336
(361) 758-5858 fax: (866)848-5457

THIS IS AN AUTHORIZATION TO APPLY CHARGES TO MY CREDIT / DEBIT CARD

Being the cardholder and by stating I Agree, at the bottom of this form, I understand and agree to the charges set forth and
specifically authorize City Cab to make a one time charge to my Credit / Debit Card. I further understand that in the event my card
becomes invalid, for any reason, before the charge has been successfully completed, I agree to remain responsible for the
charge agreed upon in this authorization.

TAXI SERVICE TO BE PROVIDED TO:

AMOUNT I AGREE TO BE CHARGED TO MY CARD $

NAME AS IT APPEARS ON THE CARD:

CARD NUMBER:

EXP DATE:

CODE:

Discover

AMEX

Master Card

Visa

THIS IS A:

BILLING ADDRESS FOR THIS CARD:

(include Street, City, State, Zip)

PHONE NUMBER ASSOCIATED WITH THIS CARD:

Other Phone No (mobile) etc. to reach you (if different from above)

YOUR EMAIL ADDRESS (for Receipt Purposes)

Before you click on the Submit Button, please check the address block above to insure that it begins with https. This
indicates that the information you have submitted will be transmitted on our secured server. Your completion of this form
helps us to protect you, our valued customer, from credit card fraud. City Cab will keep all information you provide, on this
form, strictly confidential and will not supply it to a third party except to law enforcement.

BY THIS AUTHORIZATION, I HEREBY GIVE MY COMPLETE APPROVAL TO PAY IN FULL, THE AMOUNT I
HAVE AUTHORIZED ABOVE FOR THE SPECIFIC SERVICES THAT I HAVE DIRECTLY ORDERED AND
AUTHORIZED TO BE BOOKED BY CITY CAB. I FURTHER UNDERSTAND THAT IN THE EVENT I CANCEL
THIS BOOKING, I WILL BE CHARGED A $10.00 CANCELLATION FEE.

If you agree to the terms of this authorization, please type "I Agree"
(This is considered your electronic signature)