Credit Card Payment Authorization Form
This form is standard in the rental industry. It will authorize Price’s Rentals to debit to your credit card listed below. By signing this form, you give Price’s Rentals permission to debit your account for the $250 date deposit, and/or your remaining balance (60 days prior to your event date), and any other amounts that may be needed to cover the costs that are outlined in the ‘Liability Release Contract’.
This does not provide authorization for any additional or unrelated debits to your account. Before we charge your card, you will be given notice and sufficient evidence to justify the reasonable charge. This form also acts in place of a cash damage deposit, so this form must be filled out in its entirety and signed prior to any rental commencing.
Please complete the information below:
I ____________________________ authorize Price’s Rentals to charge my credit card
(full PRINTED name)
account indicated below for the rental service scheduled for __________________.
(date of event)
Billing Address ____________________________ Phone #_______________________
City, State, Zip ____________________________ Email ________________________
Circle Account Type: Visa MasterCard AMEX Discover
Cardholder Name ________________________________________________
Account Number ___________________________________________ _
Expiration Date ____________
CVV2 (3-digit number on the back of Visa/MC, 4 digits on the front of AMEX) _____
I authorize the above-named business to charge the credit card indicated in this authorization form per the terms outlined above and in the ‘Liability Release Contract’. This payment authorization is for the goods/services described above. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form and on the ‘Liability Release Contract’.