Secure Credit Card Payment

Name: *

Home Address:

Email Address: *

Email Confirmation: *

Telephone:

Driver's Licence Number:

Licence Issue Date:

Licence Expiry Date:

Driver's Date of Birth:

Flight Arrival Info:

Flight Departure Info:

Guest House / Hotel:

Pickup Time/Location:

Return Time/Location:

Card Type:   Visa Mastercard *

Card Number: - - - *

Expiry Date: month 01 02 03 04 05 06 07 08 09 10 11 12   /   year 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 *

CVV/CVC Security Code: *

Payment Amount in TT$:

Notes or Comments:

I authorize Taylor's Jeep & Car Rentals to charge the above credit card to the maximum amount shown in the 'Payment Amount' field above.     *

* Indicates a REQUIRED FIELD