Credit Card Authorization — Bail Bond Release Center of the Palm Beaches

1 Charge details

Defendant name *

Bond amount(s) ($) *

Premium is 10% per bond ($100 minimum each). A $500 + $1,000 bond = $200, not $150. Upload the blotter above and we'll split it.

Total premium (10%)

Amount to charge this card ($) *

2 Cardholder & card

Cardholder name (as on card) *

Billing address *

City

State / ZIP

Card type

Card — last 4 digits *

Expiration (MM/YY)

Cardholder phone *

Email for receipt

🔒 For your security we only collect the last 4 digits here. The full card is entered on our secure Clover terminal — never by email or text. This signed form authorizes the charge and protects both of us in a dispute.

💵 Prefer to pay another way?

You can send the premium by Venmo, Zelle, or Cash App. Please still complete and sign this form so we have your authorization on file.

3 Photo ID & location

Required to authorize a card-not-present charge. Snap the ID and a selfie.

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ID — FRONT

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ID — BACK

🧾

Blotter / bond

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Live selfie w/ card & ID

Camera only — no uploads

Not captured yet

4 Authorization & signature

Type cardholder full name *

Date

Cardholder signature *

Sign with finger or mouse

I am the authorized cardholder and I authorize the charge described above.

🔒 By signing, you consent to us automatically capturing your device's GPS location, IP address, and the date & time to verify this authorization.

1 Charge details

2 Cardholder & card

💵 Prefer to pay another way?

3 Photo ID & location

4 Authorization & signature

Authorization signed!