Payment & Credit Card Authorization

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PCI-DSS Tokenized Data Standards

E-SIGN & UETA Valid

Legally Binding Digital Signature

Carrier Verification

Licensed & Insured Operator

Official Merchant Authorization

Ground Transportation Payment Form

24/7 Desk: (832) 555-0199

Cardholder & Client Billing Information

Full Customer / Client Name *

Company / Organization (Optional)

Billing Email Address *

Direct Phone Number *

Cardholder Billing Street Address *

City *

State / Province *

Postal / ZIP Code *

Booking & Vehicle Fleet Specifications

Quote # / Booking Reference (If known)

Specific Vehicle Category *

Service / Departure Date *

Scheduled Pickup Time

Pickup Address / Terminal *

Destination / Dropoff Address *

Estimated Number of Passengers / Guests

Payment Authorization Details

Authorized Amount ($ USD) *

Authorization Scope *

Name Exactly as Printed on Card *

Card Brand / Type *

Card Last 4 Digits * Full card details processed via encrypted merchant gateway.

Card Expiration Date (MM/YY) *

Legal Disclosures & Policy Agreements

Please review our official agreements before signing:

Cardholder Binding Authorization Statement:

I hereby authorize WealthProfusion LLC to charge the indicated credit/debit card for the agreed transport services, including any scheduled deposits, final charter balances, approved itinerary extensions, bridge tolls, and applicable cleaning or damage fees ($350 for smoking/vaping; $300–$500 for biohazard sanitization).

I understand that reservation deposits are designated for dedicated vehicle staging and driver dispatch. I agree to the cancellation cutoff timelines set forth in the Cancellation Policy. I acknowledge that filing an unwarranted chargeback or claiming "Services Not Rendered" after transportation services have been provided constitutes merchant fraud, and I agree to resolve all billing inquiries directly with WealthProfusion LLC support desk before initiating any financial dispute.

I have read, understood, and agree to the Terms of Service governing passenger conduct, booking confirmation, and carrier liability limits. * I acknowledge and accept the Cancellation & Refund Policy, including non-refundable deposit terms and cancellation cutoff timelines. * I agree to the Payment & Billing Policy, including overtime rates, incidental security holds, and vehicle cleaning rules. * I agree to the Chargeback & Dispute Policy and agree to contact WealthProfusion LLC support directly before filing bank disputes. * I accept the Privacy Policy and authorize digital verification of this transaction. *

Legally Binding Electronic Signature

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Signing Timestamp: September 27, 2026 - 4:01 PM CDT • Security IP: 216.73.216.255

100% Legally Binding

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