Credit Card Authorization Form

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Bond Information

Details of the bond this payment applies to.

Today's Date *

Enter today's date.

Agent / Employee

Defendant's Name *

Enter the defendant's name.

Date of Birth

Total Bond Amount

Credit Card Information

If Other, Specify

Cardholder Name (as shown on card) *

Enter the name printed on the card.

Card Number *

Check the card number — some digits look wrong.

Expiration Date (mm/yy) *

Use MM/YY, and check it hasn't passed.

CVV (3 or 4 digits) *

Enter the 3 or 4 digit code.

Cardholder ZIP Code *

Enter the billing ZIP code.

Amount of Today's Charge

Dollar Amount In Words

Numerical *

Enter the amount to be charged.

Authorization

I hereby authorize the charging(s) of my credit card as indicated.

By signing this credit card authorization form you are also granting Apex Bail Bonds 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 for this bail bond(s). The undersigned accepts and agrees to all of the bond terms and financial obligations as stated in the bail bond indemnity agreement and addendum and acknowledges that they are a part of this credit card authorization form for future charges. I 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. Facsimile and Electronic E-Sign copy of this form is considered as if an original.

NOTE: Charges are subject to a processing fee of 4% that will be subtracted from any refund or returns owed, an additional $150.00 application/posting processing fee may be applied for any cancellation. Premium is fully earned upon the posting of the bond(s) with the jail or court.

I HAVE READ AND AGREE TO ALL OF THE ABOVE.

I have read and agree to all of the above.

Signature

The PDF leaves a blank line for the cardholder's handwritten signature.

Indemnitor & Card Holder (Print) *

Enter the printed name.

Email completed form(s) with copy of the credit card and government issued I.D.
(434) 549-2799 · fshanksiv@apexbailbond.com · www.apexbailbond.com · 509 Loyal St., Danville, VA 24541