*Print, then fax, email or submit online this form authorizing payment of $ along with the application of the signed bond agreement.
METHOD OF PAYMENT:
Check (enclosed)
Credit Card:

Master Card Visa Discover

Credit Card #
-
-
-
Expire Date
/
CVV#
(on the back of the card)
AmerXpress
(AMEX special boxes different than above)
AMEX Card #
-
-
Expire Date
/
CVV#
(on the front of the card)
Cardholder's Name (print):
Cardholder's Billing Address:
City
State
Zip

I hereby authorize the charging(s) of my credit card as indicated.
By signing this credit card authorization form you are also granting us permission to charge your card and the use of your signature on file for any additional charges that may arise in the future pertaining to your obligation/s as an indemnitor for this $ license bond(s). The undersigned accepts and agrees to all of the bond terms and financial obligations as stated in the license bond indemnity agreement and acknowledges that they are a part of this credit card authorization form for future charges. I agree to indemnify and hold harmless the surety or its agent for all losses in connection with this bond(s) not otherwise prohibited by law. Facsimile copy is considered as if an original.
NOTE: Charges are subject to a processing fee of 3% that will be subtracted from any refund or returns owed, an additional $150.00 application/ posting processing fee may be applied for any cancellation. Premium is fully earned upon the issuing of the bond(s).
I HAVE READ AND AGREE TO ALL OF THE ABOVE.

Card Holder's Signature:  
Applicant or name on bond:
Type of bond:
Bond number (if you know it):
Amount of Bond: $
Amount of premium charged to credit card: $
Phone number:
Email Address:

This completed form will be emailed to the above address.