Credit Card – KIS Corporate

Credit Card Payment

Name*
First Last
Company Name*
Address*
Street Address City State Post Code
Email*
Phone*
Card Information
Card Type*
- Visa
- Mastercard
- AMEX
Card Surcharges
Cardholder Name*
Card Number*
Expiration Date*
Security Code*
CVV on back of card
Authorisation Date*
MM slash DD slash YYYY
Confirmation of Authorisation*
- I authorise KIS Transport Pty Ltd or KIS Corporate Pty Ltd to charge the credit card indicated in this authorisation form according to the terms outlined above. This payment authorisation is for the goods/services for KIS Transport or KIS Corporate only. I certify that I am an authorised user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
*
I authorise KIS TRANSPORT PTY LTD or KIS CORPORATE PTY LTD to debit my credit card for the amount indicated every Friday for your invoice received on the previous Wednesday. This is permission for an automatic debit each week, and does not provide authorisation for any additional unrelated debits or credits to your account.
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