PAYMENT AUTHORIZATION FORM

PAYMENT AUTHORIZATION FORM

I First Name Last Name , hereinafter called CARRIER do hereby authorize MarWest Logistics LLC, hereinafter called DISPATCH, to initiate a weekly debit entry on Friday for the amount of 10% of every load dispatched as agreed upon to the credit card account indicated below, in consideration of the dispatching service provided to me. I understand that my signature on this authorization form, along with a photocopy of the front and the back of both my credit card, as well as my driver license, will allow me the convenience of not having to produce these items for impression at the time of service.

Name on the Card:   First Name   Last Name
Please PUT X on One: VISA   MC
DISC      AMEX
Credit Card Number:
Expiration Date:   Date   CVN:      ZIP:
Authorized Payment Amount:
10% of each Load Dispatched

This authorization is to remain in full force and effect until dispatch service is discontinued. I understand that I will be notified via email when DISPATCH debit my account each week. I understand that if the load is tendered and accepted by me, but for any reason, whether is due to the carrier, shipper, or broker, the load gets rescheduled or cancelled, I am still responsible for paying DISPATCH. To cancel this automatic payment authorization, DISPATCH is to be notified by CARRIER in writing in a timely manner as to afford DISPATCH a reasonable opportunity to act on it

Signature