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202 W. Huntington Drive Monrovia, CA 91016 Ph# 626-358-2508 Credit Card Authorization FAX PLEASE FAX TO : 626-303-8022
PLEASE FAX A COPY OF YOUR DRIVERS LICENSE ALONG WITH THIS AUTHORIZATION SHEET.
I hereby authorize (print name)____________________________Simon Equipment to use my MasterCard, Visa, or American Express at Simon Equipment Co., Inc. for the rental of (name of equip)_____________________ On (date of rental)________________
I agree to all the terms and conditions of the contract and have been faxed a copy of these terms and conditions. (please initial)____________
I understand the person I have authorized (above), knows how to use and operate the equipment safely. (please initial)____________
I as the cardholder am assuming complete financial responsibility of the equipment if lost, stolen, or not returned as estimated. (please initial)_____________ Today’s Date: ______________ Please Circle One: MC VI AX
Card #____________________________________________________ Expiration date ___________________ Last 3 digits on the back of VI or MC ______________ or 4 digit number on front of AX _______________ Complete billing address for card: ______________________________________________________________ Zip Code ___________ Card holders address if different from above ____________________________________________________ Full name printed on the card _________________________________________________________________ Cardholder’s CDL # ________________________________ State ____________________________________ Cardholder’s signature ____________________________ Printed name ______________________________ Contact Ph# of cardholder _________________________ Cell # ______________________________________
IF BUSINESS PLEASE COMPLETE Business name ________________________________________________________________________________________ Complete business address _____________________________________________________________________________ Business Ph# ___________________________________ Business Fax # ______________________________________
THIS MUST BE FILLED OUT COMPLETELY !!!!!!!
202 W. Huntington Drive Monrovia, CA 91016 Ph# 626-358-2508
LONG TERM Credit Card Authorization FAX PLEASE FAX TO : 626-303-8022
PLEASE FAX A COPY OF YOUR DRIVERS LICENSE ALONG WITH THIS AUTHORIZATION SHEET.
I hereby authorize (print name)_______________________________________________ to use my MasterCard, Visa, or American Express at Simon Equipment Co., Inc. The above named may rent all equipment on an ongoing basis and has my authorization to use this card, until revoked and received by Simon Equipment in writing, or until card expires.
* I agree to all the terms and conditions of the contract and have been faxed a copy of these terms and conditions. (please initial)____________ * I understand the person I have authorized (above), knows how to use and operate the equipment safely. (please initial)____________ * I as the cardholder am assuming complete financial responsibility of the equipment if lost, stolen, or not returned as estimated. (please initial)_____________ Today’s Date: _______________ Please Circle One: MC VI AX
Card #____________________________________________________ Expiration date ___________________ Last 3 digits on the back of VI or MC ______________ or 4 digit number on front of AX _______________ Complete billing address for card: ______________________________________________________________ Zip Code ___________ Card holders address if different from above ____________________________________________________ Full name printed on the card _________________________________________________________________ Cardholder’s CDL # ________________________________ State ____________________________________ Cardholder’s signature ____________________________ Printed name ______________________________ Contact Ph# of cardholder _________________________ Cell # ______________________________________
IF BUSINESS PLEASE COMPLETE Business name ________________________________________________________________________________________ Complete business address _____________________________________________________________________________ Business Ph# ___________________________________ Business Fax # ______________________________________
THIS MUST BE FILLED OUT COMPLETELY !!!!!!!
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