ORDER WITH CREDIT CARD

XPRESS LOGISTIC SOLUTIONS,LLC

One Time Credit Card Payment Authorization Form

Here is the signed and completed form to authorize _______________________ to make a one-time debit to XPRESS LOGISTIC SOLUTIONS, LLC credit card listed below.

We are giving them permission to debit in the account for the amount indicated on or after the indicated date.  This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to our account.

Please complete the information below:

I authorize __________(full name)____________ to charge my credit card account indicated below for _______(amount)_______  on or after ________(date)________.

This payment is for _________(description of goods/services)__________.

Billing Address ____________________________        Phone#  ________________________

City, State, Zip ____________________________        Email   ________________________

Account Type:   Visa    MasterCard    AMEX    Discover

Cardholder Name _____________________________________________

Account Number  _____________________________________________

Expiration Date     ____________

Billing Zip Code  ____________

CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX) ______

SIGNATURE
DATE

I authorize the above-named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one-time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.