Get PH CMMTC Credit Card Authority to Charge

I aware that any changes in my credit card information requires me to submit a new Credit Card Authority to Charge form along with the photocopy of the front of my credit card. CREDIT CARD AUTHORITY TO CHARGE Date Citra Metro Manila Tollways Corporation CMMTC 3/F Toll Operations Bldg. Do a Soledad Ave. Brgy. Don Bosco Para aque City This is to authorize Citra Metro Manila Tollways Corporation CMMTC and its Authorized Credit Card Bank Host Provider to charge my Credit Card for the replenishment of my AUTOSWEEP RFID Account in accordance with the selected mode and the credit card information as provided below CREDIT CARD DETAILS Card Holder s Name Credit Card No* Card Type MasterCard Visa JCB Amex Issuing Bank Expiry Date MM/YY Auto Replenishment Amount P500 Min* Amount P1 000 P2 000 P3 000 P5 000 Other Amount Pls. Specify P AUTOSWEEP RFID ACCOUNT DETAILS Account Name Account No* Email Address Landline No* Mobile No* Threshold Amount P500 Default P1 000 P2 000 P3 000 P5 000 NOTE An Authorization letter from the credit card holder is required along with the photocopy of the front face of the credit card if the credit card holder and the I voluntarily disclose the above information for my AUTOSWEEP RFID load replenishment. I understand and agree that this arrangement shall be on a continuing basis unless cancelled in writing by the undersigned or as deemed necessary by Citra Metro Manila Tollways Corporation* I am aware that I am responsible in updating my credit card information two 2 months before my credit card expiration to avoid discontinuance of my automatic replenishment arrangement. I fully understand and agree that failure to debit my account due the credit card issuer s dishonor of my credit card for whatever reason will result to the immediate cancellation of this authorization without prior notice. PRINTED NAME SIGNATURE To be filled up by AUTOSWEEP RFID Account Management Group Customer Care Front-Office Customer Care Back-Office Date Received Received Verified by Date Processed Location Processed by Remarks. CREDIT CARD AUTHORITY TO CHARGE Date Citra Metro Manila Tollways Corporation CMMTC 3/F Toll Operations Bldg. Do a Soledad Ave. Brgy. Don Bosco Para aque City This is to authorize Citra Metro Manila Tollways Corporation CMMTC and its Authorized Credit Card Bank Host Provider to charge my Credit Card for the replenishment of my AUTOSWEEP RFID Account in accordance with the selected mode and the credit card information as provided below CREDIT CARD DETAILS Card Holder s Name Credit Card No* Card Type MasterCard Visa JCB Amex Issuing Bank Expiry Date MM/YY Auto Replenishment Amount P500 Min* Amount P1 000 P2 000 P3 000 P5 000 Other Amount Pls. Do a Soledad Ave. Brgy. Don Bosco Para aque City This is to authorize Citra Metro Manila Tollways Corporation CMMTC and its Authorized Credit Card Bank Host Provider to charge my Credit Card for the replenishment of my AUTOSWEEP RFID Account in accordance with the selected mode and the credit card information as provided below CREDIT CARD DETAILS Card Holder s Name Credit Card No* Card Type MasterCard Visa JCB Amex Issuing Bank Expiry Date MM/YY Auto Replenishment Amount P500 Min* Amount P1 000 P2 000 P3 000 P5 000 Other Amount Pls. Specify P AUTOSWEEP RFID ACCOUNT DETAILS Account Name Account No* Email Address Landline No* Mobile No* Threshold Amount P500 Default P1 000 P2 000 P3 000 P5 000 NOTE An Authorization letter from the credit card holder is required along with the photocopy of the front face of the credit card if the credit card holder and the I voluntarily disclose the above information for my AUTOSWEEP RFID load replenishment. .