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Credit Card Authorization Form

PLEASE PRINT, SIGN AND FAX BACK TO 1-713-460-0388

PLEASE MAIL ORIGINAL WITHIN 5 DAYS TO:

DANNY MIDDLETON, 4602 FRONTIER DRIVE, HOUSTON, TEXAS 77041

 

I, _______________________________; authorize Seril, Inc. to charge my credit card;

MasterCard _______  Visa Card _______ (check one) - in the amount of $ ______________;

I am fully aware that the amount charged is non-refundable and

I accept the sale as final with no refund.

Name _______________________________________________________

(As it appears on credit card)

Billing address ____________________________________________________

(as appears on billing statement)

Card Type ____________________________________________________

(Master card or Visa card )

Card Number _______________________________________________________

Expiration date ___________ month _________ year

Telephone number _____________________________________________________

Please sign return by fax to 1-713-460-0388. Original should be mailed to above address with 5 days.

 

Signature _______________________________________________________

Date __________________________

 

Invoice

CHECK IN ___________ CHECK OUT ___________

RENTAL AMOUNT _______________________________

DAMAGE DEPOSIT ________________________________

(To be returned, providing no damage has occurred no later than 30 days after check out)

TOTAL DUE _________________________________

PAYMENT ____________________________________________

 

 

 

PAYMENT _________________________________________________

SECURITY DEPOSIT ____________________________________________

 

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please PRINT FORM , Sign Copy and Fax today to: 1-713-460-0388

Mail Original Signed Copy to Office address listed below , ( must be received within 5 days of agreement ).

Mr. Danny Middleton  4602 Frontier Drive,  Houston, Texas 77041

( suggestion : U.S. Express Mail / FEDEX / UPS - mail same day )

PLEASE ENCLOSE A COPY OF YOUR DRIVERS LICENSE
WHEN MAILING CREDIT CARD AGREEMENT FORM 

- form #2 -

please click to Rental agreement form

return to contact page          Rental agreement form