Credit Card Authorization Form

Use this form to authorize Chain Gang Towing & Recovery Agency to charge an agreed amount for towing, recovery, roadside, storage, transport, or related services.

For your security: Do not enter a full credit card number, security code/CVV, or upload photographs of a credit card. Complete the actual payment through our secure payment page, then enter only the transaction reference and last four digits below.

OPEN SECURE PAYMENT PAGE

Questions? Call (908) 642-3699.

Cardholder Full Legal Name

Contact Phone Number

Email Address

Billing Street Address

Billing City

Billing State

Billing ZIP Code

Card Type

Last Four Digits Only

Secure Payment Transaction / Confirmation Number

Tow / Service Reference Number

Authorized Amount ($)

Service / Tow Location

Vehicle Year / Make / Model

VIN or License Plate Number

Person Authorized to Approve Additional Charges (if different)

Relationship to Cardholder

Authorized Person Phone Number

Authorized Services / Notes

Authorization and Payment Terms

I certify that the information provided is accurate and authorize Chain Gang Towing & Recovery Agency to charge the agreed amount shown above to the secure payment method identified by the transaction reference and last four digits. I understand that additional chargeable work requires authorization from the cardholder or authorized person identified above; Chain Gang Towing is entitled to payment for services performed, equipment used, applicable travel, storage, and authorized work; and this form does not transmit or store my full card number or security code.

Electronic Signature — Type Full Legal Name

Signature Date

Credit Card Authorization Form

Credit Card Authorization Form

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