This is to confirm, that I ____________ _______________,
hereby give Mikes Music the authorization to use my credit card
for the purposes required by _____________ ____________,
the rental customer, to rent a musical instrument from Mikes Music
as required within the rental contract.
It is hereby understood that NO CHARGES will be applied to
my credit card during the course of the rental contract UNLESS
the instrument is damaged, lost or stolen, OR is not returned
by the due date as stated within the terms and conditions of
the rental contract.
Credit Card Information:
VISA ______ MASTERCARD ________
Number: _________ / __________ / _________ / ____________
Expiry: ________ / _________
Three Digit Verification Number on the back of the card: _____________
Your name as it appears on the credit card:
______________________________________________
The credit card statement is mailed to the following address:
Name: ______________________________________________
Address: ____________________________________________ Apt #:___________
City: _______________________________ Postal Code: ________________
Card Holder's home phone number(s):
__________________________________________________________
Date ___________________________
Signature _______________________