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Price’s Rentals

6 Lakeview Acres

Johnson Lake, NE 68937

(402) 690-1418


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) _____                              


SIGNATURE                                                                                         DATE                           


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’.

 


First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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