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Customer Payment Authorization Form
Enter the invoices and payment amounts you want to pay, and we’ll calculate the 3% processing fee.
9
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1
Full Name
*
This field is required.
First Name
Last Name
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2
Company Name
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3
Email Address
*
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example@example.com
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4
Use card on file
*
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Yes
No
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5
Last four digits
*
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6
Front of Card
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Max. file size
: 10.6MB
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7
Back of Card
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: 10.6MB
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8
Keep this card on file for future payments?
YES
NO
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9
Invoices and Amounts
*
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10
Subtotal
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11
Processing Fee (3%)
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12
Terms and Conditions
*
This field is required.
By signing below, Customer authorizes Apache Equipment Rentals to charge the credit card provided for all amounts due under this Rental Agreement. Customer understands and agrees that Apache Equipment Rentals may place a pre-authorization hold or process a security deposit ranging from
$500 to $1,000
, depending on the type, value, and risk associated with the equipment being rented. The deposit amount will be determined solely by Apache Equipment Rentals. Customer further authorizes Apache Equipment Rentals to charge the card on file for: Rental charges and extensions of the rental period; Additional rental time beyond the original rental term; Fuel charges, refueling fees, and consumable usage charges; Delivery and pickup fees; Cleaning fees; Loss, theft, or damage to rented equipment; Missing parts, accessories, keys, or attachments; Environmental, disposal, or recovery fees; Any other charges, fees, or amounts due under the Rental Agreement. Customer acknowledges that all charges incurred during or as a result of the rental may be charged to the card on file without additional authorization. Customer certifies that they are an authorized user of the credit card provided and agree not to dispute valid charges related to the rental transaction, including charges for damages, fuel, late returns, or other amounts owed under the Rental Agreement. This authorization shall remain in effect until all obligations arising from the rental have been satisfied in full.
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13
Signature (Authorize Payment)
*
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