CREDIT CARD AUTHORIZATION

You must call us to obtain the bond amount and fees charged before submitting the Credit Card Authorization Form.

CREDIT CARD AUTHORIZATION FORM

CREDIT CARD AUTHORIZATION

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

INMATE INFORMATION

Inmate's Name*

First Last

Date of Birth

Booking No

(Must provide at least a Booking Number or Date of Birth)

CREDIT CARD INFORMATION

Cardholder's Name*

*Name must match the credit card & driver's license EXACTLY

First Last

Email*

Enter Email Confirm Email

Billing Address*

Street Address City State ZIP Code

Phone*

Credit Card Number*

(Use 1234-1234-1234-1234 FORMAT)

Expiration Date*

(Please input your credit card expiration date in month/year format such as 02/14)

CVV Code*

(3 or 4 digit Security code on front or back of Card)

Bond Amount & Fees*

(This dollar amount must come from us. Please enter the agreed upon charge amount)

PICTURES

Picture of Driver License with Driver*

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.

(You must upload a copy of your driver license held next to your face for security purposes.)

Picture of Credit Card Front*

Max. file size: 256 MB.

(You must upload a legible copy of the front of your credit card. It must be a card with the name that matches the driver license.)

Picture of Credit Card Back With Signature*

Max. file size: 256 MB.

(You must upload a legible copy of the back of your credit card. It must be a card with a signature that matches the one used on our form. Unsigned cards will not be accepted.)

Signature*

(Please sign with mouse, stylus, or finger)

928-773-1997

CREDIT CARD AUTHORIZATION

CREDIT CARD AUTHORIZATION FORM