Monthly Yard Parking Rent Form

Company Name

Customer Name :

Phone :

Address :

Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us at manilarepair@gmail.com This authorization will remain in effect until cancelled.To cancel, please email 1 month prior to leave date and make sure you recieve an confirmation back. If not call as at (559) 575-2524 as soon as possible

Credit Card Information

Select Card Type

Other

Cardholder Name (as shown on card):

Card Number:

Expiration Date (mm/yy):

Cardholder ZIP Code (from credit card billing address):

CVV:

Email Address:

* I agree, authorize Manila Truck & Trailer Repair to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

EMERGENCY CONTACTS

Phone :

Name :

Relationship :

Customer Signature

Comments:

Truck #

Trailer #