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 !!!!!!!