PLEASE PRINT OUT AND COMPLETE THIS AUTHORIZATION AND RETURN TO US. 
All information will remain confidential.

Cardholder Name:   ___________________________________________ 

Billing Address: ___________________________________________

Zip      code        ___________________________________________

Credit Card Type: _____ Visa     _____ Mastercard   ____ Discover  _____ AmEx

Credit Card Number: ___________________________________________

Expiration Date: ___________________________________________

Card Identification Number (last 3 digits located on the back of the credit card):  ________

Amex Identification (4 number above the last four numbers on front of your card): _______ 

Amount to Charge:  $  ________________ (USD) 

I authorize ___________________________ to charge the agreed amount listed above to my credit card provided herein. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement. I also acknowledge there will be no charge back after agreement has been made.  Any and all deposits processed are understood by the signer to be non refundable and agrees to but not limited to  these terms and the terms stated on http://axisaudiovideopcrental.com/TermsofServiceAgreement.aspx.  Client shall remain responsible for all loss or damage to the equipement while in their possession and or control, up to and including actual replacement value for each missing or damaged item.

Cardholder – Print Name, Sign and Date Below:

Signed: ___________________________________________

Dated: ___________________________________________

Name: ___________________________________________

 
Once signed return the completed form to: 

Onsite at event :

Email at: Axisavpc@yahoo.com

Click Below for PDF of form