CREDIT CARD AUTHORIZATION FORM

Please print and complete this form, then fax to 444-TAXI, Inc at 281-821-1244. Highlight and print the entire form and sign with the credit card holders signature on the line indicated. Include a photocopy of the front and back of the signed credit card OR scan and email the completed form and the photocopies of the credit card to complete your order.

Please print clearly.

DATE: _________________________

FROM: _________________________

CREDIT CARD INFORMATION

I hereby authorize 444-TAXI, Inc to charge my (circle one):

VISA MasterCard Diners Club Discover American Express

CARD NUMBER: ___________________________________________________________

EXPIRATION DATE: ___________________________________________________________

CARDHOLDER NAME: ___________________________________________________________

CARDHOLDER SIGNATURE: ___________________________________________________________

BILLING ADDRESS: ___________________________________________________________

CITY, STATE, ZIP: ___________________________________________________________

HOME PHONE #: ___________________________________________________________

ALT PHONE #: ___________________________________________________________

ISSUING BANK: ___________________________________________________________

*For verification and your own protection, please attach a copy of the front and back of your credit card. Your order will not be processed unless these copies are included in your fax. Thank you.

YOUR EMAIL ADDRESS: ___________________________________________________________

TRIP NUMBER 100000- ___________________________________________________________

I certify that the information I have entered on this form is accurate and true.

_____________________________________________________________________________

AUTHORIZED SIGNATURE DATE