Credit Card type accepted:

Please check credit card type

 

*Card Type:   *Card Number:

 

*Expiration Date: Month Year
 
     
*Card verification#  

*Amount (00.0)   

  Payment Code 

*Customer Name

*Country Code

*Customer Phone#

Customer Cell#

*Customer Address

*City     *State     *Postal Code

Country if Non US Address 

 

I authorize this credit card to be charged for the required security deposit amount as well as any for damages that are incurred, or item that are missing from the premises.

 

*Initials            *Date  mm/dd/yy