Headquarters: 175 Middlesex Turnpike Bedford, MA 01730 Toll-Free 1-800-937-4688 Fax: 781-271-0302 OFFICES NATIONWIDE
Credit Card Rental Agreement Form
Complete, sign & fax to: 781-271-0302
I am the purchasing agent or an officer of the corporation and I am expressly authorized to sign this rental agreement for the equipment listed below:
______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
Further, it is expressly understood that we are responsible for the risk of loss or damage of the equipment at full replacement value while in our possession. If the equipment is lost or damaged, a purchase order or corporate credit card authorization form will be provided to pay for any such occurrence. It is understood that Continental Resources, Inc. (CRI) will continue to charge our credit card each month for the total monthly rental amount with applicable taxes until the equipment has been returned. Date: Card Holder’s Name: Company Name: Card Holder’s Address: City: State: Home Phone: Work Phone: Plate Number: Bank Name: Security Code (from back of card. AMX: see 4-digit code on front of card) Card Expiration Date: Monthly Product Rental: Taxes: Initial Freight and Insurance: Total Charges:
____/____/____ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ ________________ Zip: ______________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ __ __ / __ __ (mm/yy) ____________________._______ US Dollars ____________________._______ US Dollars ____________________._______ US Dollars ____________________._______ US Dollars
American Express Visa Discover
I authorize Continental Resources to submit a:
MasterCard
without my card, for the above charges. Signature of Card Holder Sale Number:
_____________________________________________
_____________________________________________ Customer Number: _____________________________________________ CRI Sales Rep: _____________________________________________