CAR Collision Center

7967 Twist Lane

Springfield, Va 22153

(703) 455-0181

Credit Card authorization by phone, fax, or email

I ________________________ authorize CAR Collision Center to

Full name (as it appears on credit card)

charge $__________ on my Mastercard - Visa - Discover card.

Please circle one

My full address is _________________________________________. This charge is for the repairs of a ____________________________.

Year Make Model

VIN# ___________________________________________________

The vehicle owners name is _________________________________.

Credit card #___________________________ exp: ____/_____

Verification code: ________

This is a non-refundable charge. There is a 2% charge for the transaction by phone.

Date: ____________

 X: _________________________ X: ________________________

Signature Printed Name