1. Easy Rent Systems, Inc.
FAX: 347-402-4900
CREDIT CARD AUTHORIZATION FORM
Date 09/05/2013
I, Taylor Davis Hickman authorize Easy Rent Systems Inc. to charge my credit card
listed below for the following services:
Please place an “X” where indicated below to show us your authorization.
SERVICE:
Classic Advertisement X All Services under EASY RENT SYSTEMS
Gold Advertisement Placement DIAMOND Advertisement
Platinum Advertisement Placement POWER BOOST TIME
Credit Card Holder (as appears on card) Taylor Davis Hickman
Credit Card Number: 4235680033348432
Expiration Date: 08/16
Credit Card Holder Billing Address 4241 33rd
Street, San Diego CA 92104
_______________________________________________________________________
Credit Card Holder Telephone # 619.346.2908
Email: taylordavishickman@gmail.com
Credit Card Holder Signature:
9/5/2013
X Taylor Davis Hickman
Taylor D. Hickman
owner
Signed by: Persona Not Validated - 1378405023248
This form authorizes the billing of this card for the following individuals or
Accounts:
AUTOMATIC RENEWALS****
If you wish for this authorization to continue automatically rebilling OR to use it for
future renewals until you notify us, please write NONE in the END DATE column.
Advertiser’sName Advertiser’sEmail Advertiser’s
Phone
Begin
Date
End
Date**
Greg Lobkowski
realjock123@yahoo.com
619-8861638 Sept 5
2013
Oct 5
2013
Taylor D Hickman
