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Card Authorization

CREDIT CARD PAYMENT AUTHORIZATION FORM

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I hereinafter called CARRIER do hereby authorize Gatscomp Logistics, hereinafter called DISPATCH, to initiate a weekly debit entry for the amount listed below, on the dates listed below, to the credit card account indicated below, inconsideration of the dispatching service provided to me. I understand that my signature on this authorization form, along with a photocopy of the front and the back of both my credit card, as well as my driver license, will allow me the convenience of not having to produce these items for impression at the time of service.
NAME ON THE CARD:
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PLEASE CHECK CARD TYPE:
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EXPIRATION DATE, AUTH# & ZIP OF THE CARD:
EXPIRATION DAATE
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ENTER CARD ZIP CODE
AUTHORIZED WEEKLY PAYMENT:
  • - select a option -
  • 9% PER LOAD (DISP ONLY)
  • 10% PER LOAD (DISP, RECORDS)
  • 12% PER LOAD (DISP, RECORDS, MAINT)
CHOOSE LOAD PAY PERCENTAGE
START & END DATES:
PAYMENT START DATE
PAYMENT END DATE
This authorization is to remain in full force and effect until the ending date listed above. I understand that I will be notified via email when DISPATCH debit my account each week. I understand that if the load is tendered and accepted by me, but for any reason, whether is due to carrier, shipper, or broker, the load gets reschedule or cancelled I am still responsible for paying DISPATCH as set out above. Any revocation shall not be effective until DISPATCH is notified by CARRIER in writing to cancel this automatic payment authorization, in such time and in such a manner as to afford DISPATCH a reasonable opportunity to act on it.
UPLOAD CARD HOLDER SIGNATURE
UPLOAD CARD HOLDER SIGNATURE
ENTER AUTHORIZATION DATE
ENTER CARD HOLDER EMAIL ADDRESS
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