EmailMe Form - Encrypted PAYMENT GUARANTEE CREDIT CARD AUTH

EmailMeForm

Unique ID
Customer/Company Name *
Phone *
### - ### - ####
Quote/Invoice/Reference # *
Credit Card Information
Cardholder Name *
First Last
Email *
Front of Credit Card *
png, jpg, jpeg files only
Back of Credit Card *
png, jpg, jpeg files only
Credit Card *

Card Number

Protected in vault Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.
Billing Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region
Driver's License must match Cardholder name
Upload Driver's License *
png, jpg, jpeg files only
Name on Driver's License *
First Last
D.L. # *
Expiration Date *
MM / DD / YYYY
Address on License *

Street Address City State / Province / Region Postal / Zip Code Country / Region
Authorization *
I do hereby authorize billing to my credit card shown above for:
* Damage to equipment
* Loss/Non-return of equipment
* Bad checks--any transaction
* Expendables, fuel or mileage charges
* Rental Charges/late equipment return/extended rental charges
* Unpaid invoices, in full or short-paid, after the date of terms has passed
Acknowledgment *
I acknowledge that if I choose to pay final invoice by credit card, invoice will include a 3% surcharge. I also acknowledge that a photocopy or fax copy of this document shall constitute the same consent as an original.
*
I acknowledge that I may be liable for up to $1000 in repairs for damage or $1000 deductible for loss if I am being charged a damage waiver by PC&E.
Signature *
Clear
Today's Date *
MM / DD / YYYY
2235 DeFoor Hills Rd NW. Atlanta, GA 30318 | (404) 609-9001 | FAX 404-609-9926
Monday - Friday 9:00am to 6:00pm

Credit Card Information

2235 DeFoor Hills Rd NW. Atlanta, GA 30318 | (404) 609-9001 | FAX 404-609-9926 Monday - Friday 9:00am to 6:00pm

2235 DeFoor Hills Rd NW. Atlanta, GA 30318 | (404) 609-9001 | FAX 404-609-9926
Monday - Friday 9:00am to 6:00pm