New Customer Set Up Form

Company Name

Point Of Contact For Receiving Equipment

First NameLast Name

Company Business License

Copy of your active business license matching the shipping address

Drivers License

A photo of the drivers license of person who signed the rental agreement

You authorize regularly scheduled charges to the payment method determined below. You will be charged the amount indicated below each billing period, in addition to any required security deposits and shipping amounts. A receipt for each payment will be provided to you by email and the charge will appear on your bank or credit card statement. You agree that no prior notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 7 days prior to the payment being collected.

I First Name* Last Name* with Company Name* authorize Equipped MD (dba Rentals MD) to charge the payment method noted below for $ Amount* on the * day of each month.

This payment is for Rental Equipment*

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Billing Point Of Contact

First NameLast Name

Billing Email*

example@example.com

Billing Phone*

Please enter a valid phone number.

Payment Method*

Bank Type*

Bank Name*

Account Name*

Routing Number*

Account Number*

Credit Card Type:*

Card Holder Name*

First NameLast Name

Number*

old do not use*

Card Expiration Date*

Date

CVV Code*

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Equipped MD Inc (dba Rentals MD) in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above-noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day

For Credit Card Transactions I acknowledge that the origination of Credit Card transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this Credit Card and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form.

For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above-noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that Equipped MD Inc may at its discretion attempt to process the charge again within 30 days, and agree to an additional $100 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form.

Signature*

New Customer Set Up Form

Billing Information