Complete this form to authorize LAX Express Travel to make a debit to your credit card listed below.

Please complete the information below:
I authorize LAX Express Travel to charge my Credit Card account indicated below for the amount of $ .

Name on Card Credit Card #* Expiration Date Card Verification #* Address City State Country Postal Code Accept the terms and conditions below

* I authorize LAX Express Travel to charge the credit card indicated in this authorization from according to terms outlined above. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; as long as the transaction corresponds to the terms indicated in this form.

* Your credit card statement will read: AWJT LAX Express LLC.

* Important note: Due to credit card regulations, a photocopy of the cardholder's card imprint (Front & Back) must be provided with a copy of the cardholder's driver's license or passport upon completion of this form.