Credit Card Holder Details

First Name *

Last Name *

Last Four Digits of Credit Card *

Expiry Date *

Email Address *

Best Phone Number *

Participant Details

Participant First Name *

Participant Last Name *

Vehicle Registration Number *

Credit Card Holder Payment Authority

I, as the card holder (as per above), hereby authorise Affordable Interlock Systems to charge my debit card for the following transaction(s) (select option):

Please Select Option *

One off PaymentInstallation Fee, Monthly Monitoring Fee, Violation Fee, Removal Fee, Charge Back Fee's or other fees associated with the interlock program.

I further acknowledge that in the event of any changes to my credit card details, the card holder is required to notify AIS immediately; however, I remain fully responsible for all charges incurred.

I understand that by signing this authorization, I am allowing Affordable Interlock Systems to debit my credit card for the specified transaction(s). I agree to fulfill all terms and conditions associated with this transaction.

I acknowledge that this authorisation is a legally binding agreement and will remain in effect until the specified transaction(s) are completed or until I provide written notice of cancellation to Affordable Interlock Systems.

I acknlowledge as the card holder I agree to accept full responsibility and shall remain liable for all payments due, including any associated late fees or bank charges.

Signature Block *

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