Credit/Debit Card Authorization

This form is required to be signed prior to your rental if you have given us payment information verbally over the phone.

In filling out this form, you authorize West County Equipment Rentals to charge your credit card for payment of goods or services.

Name*

Date*

Billing Address*

Billing Zip*

Phone*

Email*

Name on Card*

Card Number - Last 4 digits only*

Expiration Date*

Authorization*

I authorize the above named business to charge the credit card indicated in the authorization form according to the terms outlined above.

I, the cardholder, authorize West County Equipment Rentals (“the Merchant”) to store my payment card and charge it for any and all amounts owed in connection with equipment rentals, including but not limited to:

Rental fees
Security deposits
Overtime charges
Damage repair or replacement costs
Loss or theft of equipment
Cleaning fees
Fuel charges (if applicable)
Late return fees
Accessories or add-on items
Any unpaid balances on my account

This authorization applies to all current and future rentals until revoked in writing.

Your Monday Color*

Please review what you entered before you click the Submit button, and click it ONLY ONCE.