Credit Card Revision Form

Credit Card Revision Form
Your completion of this authorization form helps us to protect you, our valued customer, from credit card fraud. All information entered on this form will be kept strictly confidential. Our payment process is PCI compliant which ensures that your information is being handled in accordance with industry security standards. For more information on PCI compliance please click the PCI icon on the right of your screen.

Primary cards listed below will be charged first for any services and fees billed by Permit America, Inc. Secondary cards will only be charged if the primary card is not approved for payment. Permit America will only allow two credit cards on file. You may cancel this authorization at any time by contacting Permit America, Inc at 866-573-7648; this authorization will remain in effect until cancelled by you.
Legal Company Name(s):*
USDOT #:*
Phone
Email
BILLING INFORMATION (AS IT APPEARS ON YOUR CREDIT CARD STATEMENT)
How will this card be used?*
- Updating a primary card;
- Adding as a secondary card;
- Adding as a One Time Use card.
Credit Card Number*
Expiration Date*
CVW*
Address On Credit Card Statement:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name on displayed on card*
First Last
Consent*
I understand that Permit America will Pre-Authorize my credit card upon ordering permits. I understand the initial charge is an estimate of the total invoice including but not limited to the Agency cost and service fee per permit. If a state fee exceeds $500 an additional $25 fee will be added for every $500 increment. I understand that this Pre-Authorization will be adjusted to the full amount, including a 4% convenience fee, upon completion of the work order and the invoice generated. All rates based on US currency. I hereby authorize Permit America to charge my credit card account. I agree and accept the terms as stated above.
Signature of Name on Credit Card*
Signature Date*
MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Permit America For Your Mobile Device

You can now carry digital copies of all of the provision sheets on your favorite Android or iOS device using our new app!

Permit America Android Device Mobile App

BILLING INFORMATION (AS IT APPEARS ON YOUR CREDIT CARD STATEMENT)

Permit America For Your Mobile Device

You can now carry digital copies of all of the provision sheets on your favorite Android or iOS device using our new app!