Airport Express
.
New York, NY 14223

Phone: (716) 472 - 8580

transportation

Billing Information:

Company Name:
First Name:
Last Name:
Address:
Address Line 2:
City:
State:
Zip:
Country:
Phone Number:
Email Address:
Notes:

Account Holder Name:
Bank Routing Number:
Bank Account Number:
Bank Account Type:

Same Address as above

Name as on Card:
Card Billing Address:
Card Billing Zipcode:
Card Number:
Card Expiration Date:
Card ID (CVV2/CID) Number:

Subtotal: $

Cash Adjustment Fee: $Convenience Fee: $

Total Amount: $

This is a One-Time transaction with the Payment Effective Date of 06/07/25.
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By authorizing this transaction customer agrees that company named above may convert this transaction into an Electronic Funds Transfer (EFT) transaction to send via ACH debit to the bank account for the amount indicated above.
To revoke this authorization contact Customer Support at Phone: (716) 472 - 8580 within 48 hours prior to the Payment Effective Date.
Processing times may not allow for revocation of this authorization.
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