Complete this form so we can charge your card for the services performed. Questions? Call 606-679-9077.

Card Information

Card Type (required) Visa Mastercard Discover American Express

Cardholder First Name, as it appears on the card (required)

Cardholder Last Name (required)

Contact Phone Number (required)

Email for receipt

Billing Address (required)

Billing City (required)

Billing State (required)

Billing ZIP (required)

Photo of the front of the credit card (required)

Photo of the back of the credit card (required)

Service Details

Reference or Invoice Number (required)

Estimated Charges (required)

Cardholder Identification

Cardholder Driver's License Number (required)

Driver's License State (required)

Clear photo of the cardholder's Driver's License, for identity verification (required)

Person Authorized to Approve Work and Charges

Complete this if someone other than the cardholder is receiving the service or approving work. If the cardholder is that person, enter their details again.

First Name (required)

Last Name (required)

Relationship to Cardholder (required)

Contact Phone Number (required)

Authorization

I certify that the information above is accurate and complete, and I authorize Candido's Towing & Repair to charge the credit card above for the services performed. I understand and agree to the following:

Estimated charges may vary depending on the actual conditions encountered.
If additional work is required that exceeds the estimate, Candido's Towing & Repair will obtain approval from the cardholder or the person named above before completing additional chargeable work.
If the Estimated Charges field is left blank, I agree to pay the actual charges invoiced by the company.
The company is entitled to payment for work performed and equipment used, including travel and work actually performed if the service cannot be completed because of incorrect or incomplete information provided to the company.
Hourly charges begin when the operator leaves the shop. Cancellation after the operator has been dispatched may result in charges for the operator's actual travel time.

I have read and agree to the authorization above. (required)

Cardholder Signature (type your full legal name) (required)

Date (required)

Mon	Open 24 Hours
Tues	Open 24 Hours
Wed	Open 24 Hours
Thurs	Open 24 Hours
Fri	Open 24 Hours
Sat	Open 24 Hours
Sun	Open 24 Hours

Credit Card Authorization

Card Information

Service Details

Cardholder Identification

Person Authorized to Approve Work and Charges

Authorization