Credit Card Authorization - Rentals

If you prefer not to put your credit card information in this form, please fill out the other fields and write "CALL FOR INFO" in the 'Card Number' field.

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

Expiration

CVV (Security Code)

Authorization*

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

This payment authorization is for the goods and/or services described above. I certify that I am an authorized user of this credit card- and will not dispute the payment with my credit company; so long as the transaction corresponds to the terms indicated in the above form.''' , '(Blanket debit) By signing this form- you give us permission to debit your account for all unsettled debt- or recurring debt- on or after the date indicated.

Please select the option that applies to you*

Your Wednesday Color*

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