8/10/2019 Loring Credit Card Authorization Form

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Loring Parking Ramp CREDIT CARD AUTHORIZATION

Name: ________________Account Number: _____________ Email:_______________

Billing Address:________________ City:_________State:____ Zip:_______________

Business Address:_______________ City:_________State:____ Zip:_______________

Home Phone:____________ Business Phone: ____________Fa: __________________

Vehicle Vehicle Drivers

Make: License: Lic. No.:

Parking to commence: January 01, 01!

" here#y authori$e %llie& Parking, "nc. to charge my cre&it car& on a monthly #asis 'or

(arking charges incurre& each month. )re&it car&s *ill #e charge& #et*een the 'irst an&the 'i'th o' each month.

Credit Card

Visa M/Card AMEX Discover

Expiration Date / !ast " digits on bac# o$ card

Card Number - - -

Amex Number - - -

Valid Date /

Signature/ Authoriation

Date

%t is the customer&s responsibility to cancel the authori'ation (ith their credit card company upon

proper noti$ication to Allied Par#ing) %nc* o$ their termination o$ par#ing* %$ the customer $ails to

do so) the liability o$ Allied Par#ing) %nc* is limited to a maimum re$und o$ t(o +,- months&

par#ing payments*

All re!ected transactions carr" a #$%&'' administrative (ee&

.his agreement is sub/ect to the Par#ing Agreement +!ease- $or the Centre 0illage 1amp*

8/10/2019 Loring Credit Card Authorization Form

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I ACCEPT AND AGREE TO THIS MONTHLY PARKING AGREEMENT WITH Allied Parking, Inc.. I ACKNOWLEDGETHAT I HAE READ AND AGREE TO THE TERMS AND CONDITIONS LISTED A!OE, AS WELL AS THEMONTHLY PARKING AGREEMENT "LEASE# $OR THE CENTRE ILLAGE RAMP.

SIGNAT%RE& A%THORI'ATION()))))))))))))))))))))) DATE( )))))))))))))))