Broward Tag and Title
Pembroke Pines Agency
1441 N. Palm Ave
Pembroke Pines FL 33026
Tel: (954) 317-1769 Fax: (954) 312-7987

 

Customer / Dealer Information
%%GLOBAL_BillingAddress%%
%%LNG_Email%%: %%GLOBAL_BillingEmail%%
Additional Info
Invoice No: %%GLOBAL_OrderId%%
%%LNG_Phone%%: %%GLOBAL_BillingPhone%%
%%LNG_PaymentMethod%%: %%GLOBAL_PaymentMethod%%
Invoice Date: %%GLOBAL_OrderDate%%
%%GLOBAL_ProductsTable%%
%%LNG_Quantity%% Code Description %%LNG_Price%% %%LNG_Total%%
%%LNG_InvoiceItems%%: %%GLOBAL_ItemCost%%
%%LNG_InvoiceTotalCost%%: %%GLOBAL_TotalCost%%
%%GLOBAL_SalesTaxName%%: %%GLOBAL_SalesTax%%
%%LNG_Comments%%
%%GLOBAL_Comments%%

CREDIT & DEBIT CARD AUTHORIZATION RELEASE

I _____________________________ authorize Broward tag and title to charge my credit / debit card ending in _________ for the amount indicated on the above invoice. By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date.  This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

Sign:_________________________________   Date:____________