Minute Man Delivery

Credit Card Club Authorization Form

I, ____________________________________________________, hereby authorize Minute Man Delivery, to make charges to my Credit Card for transportation services or products as requested by me or authorized users of this credit card.  I hereby designate as authorized users of this card the following persons to make charges on said card for arrangements in the event that I am unable to personally do so (if none state “None”):

 

1.

2.

3.

4.

No other persons are authorized to make charges on said account without my express authorization.  In the event any of the above named persons make unauthorized charges against this card, I hereby agree to indemnify and hold blameless Minute Man Delivery, for any and all such charges, claims and liability related hereto.  I agree to immediately to notify Minute Man Delivery of any changes to the identity of Authorized Users.

I fully understand the services or products are non-refundable and/or are subject to penalty fees in the event changes need to be made or services and/or products need to be cancelled.

Credit Card Type:  Visa ___     Mastercard  ___      Amex ___
Credit Card Number: __________________________Exp. Date:_________
Billing Name (as it appears on credit card): ________________________________________________________________
Billing Address (where credit card statements are sent to):
 _________________________________________
 _________________________________________
                                                                        
Daytime Telephone Number: ______________________________________
Evening Telephone Number: ______________________________________

Cardholder signature: ________________________Date________________
PLEASE INCLUDE A COPY OF THE CREDIT CARD, BOTH FRONT AND BACK, ALONG WITH YOUR PICTURE I.D. (DRIVER'S LICENSE, MILITARY I.D., ETC.) 

Please fax to: 310-327-3650.