CREDIT CARD AUTHORIZATION FORM RENTAL Please provide the following information for credit card sale:Company name*Cardholder's name*Billing address of card* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* PhoneType of card*VisaMaster CardDiscoverAMEXCard number*Expiration date*V#*Three numbers found on back right hand side of Visa, Master Card or Discover onlyV#*Four numbers found on back right hand side of AMEX onlyUpload front of credit card*Accepted file types: jpg, jpeg, png.Upload back of credit card*Accepted file types: jpg, jpeg, png.Upload your personal ID*Accepted file types: jpg, jpeg, png.* I HEREBY AUTHORIZE THE USE OF THE ABOVE LISTED CREDIT CARD FOR THE RENTAL OF EQUIMENT LISTED BELOW AND EQUIPMET RENTAL AGREEMENT AND ANY ADDITIONAL CHARGES THAT MAY ARISE IN THE FUTURE UNDER THE RENTAL AGREEMENT. REPLACEMENT VALUE/DEPOSIT WILL NOT BE CHARGED UNLESS THE CONDITION OF THE RENTAL AGREEMENT REQUIRE IT.*Cardholder’s signature or authorized officer:*Printed name*Date Date Format: MM slash DD slash YYYY * THIS CREDIT CARD AUTHORIZATION FORM IS IN REFERENCE TO THE FOLLOWING SALES ORDER(S) AND APPLICABLE SHIPPING COST, PLUS 3.50 PERCENT FOR AMEX OR 2.5 PERCENT FOR VISA/MASTERCARD CREDIT CARD FEE:*Equipment*Victory Handheld Electrostatic SprayerVictory Back Pack and Electrostatic RyobiRyobi FoggerQuantity*Rental Period/Rate*Two hours minimum rental2 Hour Rate / Min24 Hour RateWeekly Rate (7 days)4 Week Rate (28 days)Rental Period/Rate*Two hours minimum rental2 Hour Rate / Min24 Hour RateWeekly Rate (7 days)4 Week Rate (28 days)Rental Period/Rate*Two hours minimum rental2 Hour Rate / Min24 Hour RateWeekly Rate (7 days)4 Week Rate (28 days)Equipment serial numbersTotal Rental Rate (Get paid now)Total Rental Rate (Get paid now)Total Rental Rate (Get paid now)Replacement value / Deposit Price: $795.00 Replacement value / Deposit Price: $1,995.00 Replacement value / Deposit Price: $150.00
