Credit Card Holder Details

First Name *

Last Name *

Last Four Digits of Credit Card *

Expiry Date *

Email Address *

Best Phone Number *Example +61412345678

Participant Details

Participant First Name *

Participant Last Name *

Vehicle Registration Number *

Credit Card Holder Payment Authority

Please Select An Option *

I further acknowledge that i n the event of any unauthorised charges 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 authorisation, 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 acknowledge as the card holder I agree to accept full responsibility and shall remain liable for all payments due, including any associated late fees, bank charges and any debt collection fees.

Signature Block *

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AIS-NET-O-015

03JUL2024 V1.0