Official Payment Form

Credit Card Authorization

Complete all fields, upload the required identification, and sign below to authorize the charge. Your information is transmitted over an encrypted connection.

Cardholder Information

Full Name (as on card) *

Email Address *

Phone Number *

Billing Address *

City *

State *

ZIP *

Payment Details

Card Type *

Last 4 Digits of Card *

Expiration (MM/YY) *

Amount to Authorize (USD) *

Authorization Type *

One-Time ChargeRecurring / Keep on File

Description of Service / Invoice #

Identification Upload

The name on the credit card MUST match the driver's license.

Both photos are required. Please make sure all numbers, names, and dates are clearly readable. Files are stored encrypted and used only for payment verification.

Credit Card Photo (front) *

Click to upload or drag & drop

JPG / PNG / WebP, up to 8MB

Driver's License Photo *

Click to upload or drag & drop

JPG / PNG / WebP, up to 8MB

Authorization & Signature

I, the cardholder named above, authorize Tri-State Heavy Repair to charge the credit card indicated for the amount stated. I certify that all information provided is accurate and that the name on the credit card matches my driver's license. I understand this authorization will remain in effect until I notify Tri-State Heavy Repair in writing to cancel it.

Signature *

Sign here with mouse or finger

Date *

I acknowledge that the name on the credit card matches my driver's license, and I authorize Tri-State Heavy Repair to charge my card as described above.

Encrypted end-to-end. Deleted from our servers after email.