Tot Town Rental

Credit Card Authorization Form

Name of Renter *

Name of Renter

First Name

Last Name

Email Address *

Phone *

Phone

(###)

###

####

Complete Address *

Complete Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorization

By checking the box, I hereby authorize Tot Town LLC to debit the account associated with the credit card information provided below for all rental fees and additional surcharges as stipulated in the Rental Agreement, which I have reviewed, acknowledge and am in full agreement with. I understand that if any charge is declined, I must remit payment due immediately via cash or certified check

Credit Card Number

Credit Card Expiration Date mm/dd/yyyy

Credit Card 3 Digit Security Card

Credit Card Zip Code

Name as it appears on Credit Card