CREDIT CARD BY FAX AUTHORIZATION

QER ACCOUNT #: _____________________

CUSTOMER/COMPANY:__________________________________________DATE:____________

HOME PHONE:________________________CELL NUMBER:__________________________

COMPANY PHONE:_____________________FAX NUMBER:___________________________

HOME ADDRESS:____________________________________________________________

CITY/STATE/ZIP CODE:_____________________________________________________

CALIFORNIA DRIVER LICENSE # :____________________________________________

LIC. EXPIRATION DATE:__________________________DATE OF BIRTH:____________

CREDIT CARD # :____________________________EXP. DATE (month/year):_______

CREDIT CARD CODE #:____________________________

NAME IMPRINTED ON CREDIT CARD:___________________________________________

HOW DID YOU FIND OUT ABOUT OUR COMPANY?__________________________________

The person(s) listed below are hereby authorized to act on behalf of Customer/Company listed above in connection with the rental of equipment, tools and other property from Quality Equipment Rentals and to conduct any and all other related business on behalf of the Customer/Company.  Customer/Company agrees to be fully bound by the terms and conditions of the Rental Contract and any other agreement, waiver, acknowledgment, receipt or other authorization executed or otherwise agreed to by such person(s) as if duly authorized and agreed to by Customer/Company themselves.
Customer/Company acknowledges and agrees that this authorization is a continuing one and shall apply to the rental of all items of equipment, whether identified in the Rental Contract or subsequently obtained by such persons(s) from Quality Equipment Rentals and Customer/Company agrees to timely pay all rental and other charges incurred therewith.

_______________________________________________________________________________________________
(Cardholder signature)                                                         (please print name)    ________________________________________________________________________________________________
(AUTHORIZED NAME)                                                 (DRIVER LICENSE #) ________________________________________________________________________________________________
(AUTHORIZED NAME)                                                 (DRIVER LICENSE #)

DO YOU WANT US TO KEEP THIS INFORMATION ON FILE FOR FUTURE RENTALS?           YES           NO