I authorize Off The Hook Bail Bonding or any agents or members of Off The Hook Bail Bonding to charge my credit card the amount specified below, for bail bonding services contracted for the defendant listed below on the date listed below.

Defendant Name*

Amount*

Date*

By signing this credit/debit card authorization form you are also granting us permission to charge your card and the use of your signature on file for any additional charges that may arise in the future pertaining to your obligation(s) as an indemnitor and/ or defendant for this bail bond(s). The undersigned accepts and agrees to all of the bond terms and financial obligations and acknowledges that they are a part of this credit card authorization form for future charges. You agree to indemnify and hold harmless the surety and its agent for all losses in connection with this bond(s) not otherwise prohibited by law. The amount charged is not to exceed 15% of the premium or whatever the total face value of the bond may be for collateral. Facsimile, electronic e-sign copy of this form, and documented phone conversation is considered as if an original.

Card Holder Information

Card Holder Signature*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Payment Information

Name As It Appears On Card*

First Last

Card Number*

Expiration Date*

3 or 4 digit code on back*

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