Dirty Boyz Waste Solutions

Credit Card Authorization Form

Securely provide your payment authorization below.

Important Security Notice

Your security is our priority. We do not store your full credit card number or CVV code. Only the last 4 digits are kept for reference purposes. All submissions are processed securely.

Customer Information

Full Name *

Email Address *

Phone Number (Optional)

Card Information

Name on Card *

Card Type (Optional)

Card Number *

Expiry Date (MM/YY) *

CVV *

Billing Address for Card *

Must match the address associated with the credit card.

Authorization Details

Select Authorization Type *

One-time Payment: Authorize a single charge (specify amount below if known).

Recurring Payments: Authorize charges for ongoing services as per our agreement.

Keep Card On File: Authorize us to keep card details securely (last 4 digits only) for future or incidental charges (e.g., overages, additional services) as agreed.

Specific Amount Authorized (Optional, for One-time Payment)

Only required if selecting "One-time Payment" for a specific, known charge amount.

Agreement & Signature

Credit Card Authorization Terms

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

By checking the box below and submitting this form, you authorizeDirty Boyz Waste Solutions to charge the credit card provided for agreed upon purchases according to the authorization type selected. You understand that your information will be saved to file for future transactions on your account, according to our security practices (we do not store full card numbers).

Please review the terms carefully before checking the agreement box and signing below.

I have read and agree to the Credit Card Authorization Terms stated above. *

Digital Signature (Type Full Name) *

Typing your name acts as your legally binding signature confirming your agreement.

Questions?

If you have any questions about this authorization, please contact us before submitting.