COD Deposits

Dispatch Number:*

Customer/Business Name:*

Phone:*

Cardholder Name:*

Email Address for Sending Receipt:*

Address*

Billing Address: Box/Ste. City State ZIP Code

Billing Information*

Visa
MasterCard
Amex

Card Number*

Exp. Month:*

Exp. Year:*

CVV*

agree that the information submitted is correct*

I am an authorized customer/business representative and hereby agree to the Terms & Conditions on behalf of the customer/business “Lessee” named above. I agree that the information submitted is correct to the best of my knowledge and understand that my rental is not secured unless the company is able to successfully process the above deposit information. Terms and Conditions shall apply to all work performed by Phoenix Crane Service Inc. (“Lessor").*

Signature*

Customer

Employee

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