Foot Scooters, LLC
TLC Knee Caddy Rental Payment Authorization
PREAUTHORIZED AUTHORIZATION PAYMENT(S) AGREEMENT
Payment approval for TLC KNEE SCOOTER RENTAL, DEPOSIT and SHIPPING Charges
I (we) hereby authorize Foot Scooters, LLC hereinafter called COMPANY, to initiate debit entries to my (our) Checking / Savings account indicated below and the bank depository named below, hereinafter called DEPOSITORY, and to debit the same to such account. BANK DEPOSITORY NAME:_________________________________________________________ BANK BRANCH:____________________________________________________________________ CITY ______________________________ STATE ___________ ZIP ______________________
BANK ROUTING / TRANSIT/ABA NO. ______________________________________________ (Where do I find this information?) CHECKING OR SAVINGS ACCOUNT NO. __________________________________________ (Where do I find this information?) Statement of DEBIT AUTHORITY AUTHORIZATION TERMINATION : This debit authority authorization will remain in full force and in effect as stated within the provisions of the TLC Knee Caddy rental contract. If and when owner provides written notification stating the termination of this debit authorization and in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it, the parties agree that termination of this debit authority authorization and rental contract will be executed by the company only after the rented TLC Knee Caddy has been returned per the return instructions and/or the deposit has been relinquished to close out the rental contract. Furthermore, it is agreed to that no pro-rated rent collected will be due or payable back to this account or its owners if this agreement is terminated within the first four (4) weeks of its commencement. The $40.00 weekly rental fees will apply as agreed to or until such time the full deposit is relinquished in order to satisfy the termination of the TLC Knee Caddy scooter rental agreement.
Please print the signature name (name(s) when a joint signature is required) of the Owner(s) authorized to sign on the Checking / Savings Account accounts: 1. ______________________________________________ 2. _______________________________________________
Signature: Sign below same as on check and or savings account:
X _____________________________________________ X _____________________________________________
Driver License Number: ____________________________ State: _________________________________ Renewal Date:________________________
Driver License Number _______________________________ State: _________________________________ Renewal Date:__________________________
Attach a signed voided check or withdraw slip below. The check or withdraw slip should be made out to Foot Scooters, LLC for the amount of the first four weeks of rental, deposit and shipping as stated in the rental agreement contract. If the knee caddy rental has not been returned by the beginning of the fifth (5) week of the rental per the rental instructions, the weekly rental fee of $40.00 will be debited from the account as authorized above. This weekly $40.00 fee will be debited weekly until the rental unit is returned per the return instructions.
Attach a signed and voided check or withdraw slip and a copy of signature’s driver licenses and fax back to 1(830) 885-4985 to process this rental order and payment.
If you need any assistance please call Foot Scooters, LLC at 210-683-6480.