Credit Card Authorization Form

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Credit Card Authorization Form You may now pay invoices via credit card authorization. If you wish to make payment this way, please send in the form below completely filled out. Thank you. Name on Account:________________________________________________________ Account Number:__________________________Today’s Date:___________________ Payment is for: Invoice # Amount _____________ _______________ _____________ _______________ _____________ _______________ _____________ _______________ _____________ _______________ _____________ _______________ Total Amount:_________________________________________ ( ) Mastercard

( ) Visa

( ) Discover

( ) American Express

Cardholder Account #:_____________________________________________________ Expiration Date: ______________________________________________________ Cardholder Name: ______________________________________________________ Billing Address for Card: __________________________________________________ __________________________________________________ Cardholder Signature: ___________________________________Date: _____________ Would you like a receipt: ( ) Yes ( ) No ( ) Use this card for future purchases ( ) Use this card for today’s purchase only

Orange: 304 Boston Post Road Orange, CT 06477 (203) 795-5251 Fax (203) 795-9481 Branford: 174 Cedar Street Branford, CT 06405 (203) 488-1644 (203) 483-7547 Monroe: 517 Main Street Monroe, CT 06468 (203) 268-6241 Fax (203) 261-4538 Web site: www.taylor-rentals.com