Credit Card Authorization Form


This is to confirm, that I ____________ _______________,
hereby give Mikes Music the authorization to use my credit card

for the purposes required by _____________ ____________,
the rental customer, to rent a musical instrument from Mikes Music
as required within the rental contract.

It is hereby understood that NO CHARGES will be applied to
my credit card during the course of the rental contract UNLESS
the instrument is damaged, lost or stolen, OR is not returned
by the due date as stated within the terms and conditions of
the rental contract.

Credit Card Information:

VISA ______ MASTERCARD ________

Number: _________ / __________ / _________ / ____________

Expiry: ________ / _________

Three Digit Verification Number on the back of the card: _____________

Your name as it appears on the credit card:

______________________________________________

The credit card statement is mailed to the following address:

Name: ______________________________________________

Address: ____________________________________________ Apt #:___________

City: _______________________________ Postal Code: ________________

Card Holder's home phone number(s):

__________________________________________________________



Date ___________________________


Signature _______________________