MetroCard Credit Card Payment - (2017)

Fax Completed Form To: 646-252-6599

Billing Information:

Is the address below a Residential or Commercial

Corp Name

Doing Business as (DBA) (If Applicable)

Business Type

Tax ID

Address (No PO Box #)

Address 2

City State Zip

Hrs of Operation Mon through Friday AM to PM

Country (If Applicable)

Email Address

Contact Name

Telephone

Shipping Information:

(Complete if different than billing information)

Is the address below a Residential or Commercial

Name of Business

Address 1 (No PO Box #)

Address 2

City State Zip

Country (If Applicable)

Contact Name

Business Telephone #

Credit Card Information:

Credit Card Type: MasterCard Visa American Express Discover
Credit Card Number
Expiration Date
Card Holder's Phone #
Credit Card Holder
Credit Card Address
City
State
Zip
Country (If Applicable)

METROCARD INTIAL ORDER:

MetroCard Denominations	Price
$5.50 MetroCard w/ Bonus (50 cards per Batch) @ $275.00 per batch
$10.48 MetroCard w/Bonus (50 cards per Batch) @ $524.00 per batch
$20.95 MetroCard w/ Bonus (50 cards per Batch) @ $1047.50 per batch
$26.19 MetroCard w/ Bonus (25 cards per Batch) @ $654.75 per batch
$39.29 MetroCard w/Bonus (25 cards per Batch) @ $982.25 per batch
$61.90 MetroCard w/Bonus (10 cards per Batch) @ $619.00 per batch
$5.00 AirTrain MetroCard (50 cards per Batch) @ $250.00 per batch (FOR USE ON AIRTRAN ONLY)
$25.00 10-Trip AirTrain MetroCard (10 cards per Batch) @ $250.00 per batch
$40.00 AirTrain 30-Day Unlimited (10 cards per Batch) @ $400.00 per batch
$59.50 7-Day Express Bus Unlimited (25 cards per Batch) @ $1,487.50 per batch
$32.00 7-Day Unlimited (50 cards per Batch) @ $1,600.00 per batch
$121.00 30-Day Unlimited (10 cards per Batch) @ $1,210.00 per batch
Total Cost:

PLEASE NOTE: After Completing the Credit Card Application,
complete the MetroCard Merchant Sales Agreement Contract (PDF file, 50K).
Print, Sign and Fax both forms to (Secure) Fax # 646-252-6599.

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