Credit Card Authorization Form

Fill out this form if you want to be able to charge equipment without coming to the office via personal or company credit card.

Company Name: (Use this if rental is for a business)
Name: (Use this for contact information)
Address: (Use business address if company will pay bill)

Home/Bus Phone:

(enter as xxx-xxx-xxxx)

Cell Phone:

(enter as xxx-xxx-xxxx)
Email Address: (enter address that you would like a response to)
Driver's License #: State of Issuance: (please enter your valid drivers license number and state of issuance)
Name on CC: (enter the name exactly as it appears on credit card)
Credit Card #: Exp Mo:   Exp Yr:    Sec. Code:  Billing Zip: 
Agree:    If checked, you agree to allow us to use the credit card entered here as payment for outstanding invoices on your account. If you do not check this button, you do not authorize us to use credit card for payment of outstanding invoices.  You agree that this is your credit card or you are authorized by the account holder to use their card for these transactions.