Laserfiche WebLink
DocuSign Envelope ID: 7CA2339D-D38F-4A93-B76C-6A783781542B <br />'In <br />environn'ental <br />CONFIDENTIAL <br />Credit Card <br />Authorization Form <br />Qua Iit Pro' <br />12973 83rd Ave. For Office Use Only <br />Location. #: 679113 ❑Bill-Tc❑ILocation Branch: 02 Treasure Coast <br />I hereby authorize Hulett Environmental Services <br />to charge my credit card for services rendered as indicated below: <br />Name on Credit Card: <br />Billing Address: <br />Phone #: <br />Billing zip code: <br />Type of Card: 0 Visa _,i Master Card � American Express / Discover U GreenSky <br />Card #: <br />Expiration Date: <br />0 Update existing card on account <br />1. ❑ Program <br />(customer initials) <br />Authorization for Initial service payment of. $ <br />❑ PC $ n Lawn $ n Termite $ <br />and to charge card after each regularly scheduled service or annual program. <br />❑ PC $ n Lawn $ n Termite $ <br />2.FV—] Authorization to charge card one time in the amount of $ 1,027.00 <br />❑ PC $ Lawn $ n Termite $ 1,027.00 <br />❑ Advance Renewal $ <br />❑ Bad Debt Balance $ <br />3. ❑ Authorization for down payment of services, and charging balance due after completion of service. <br />Down Payment Charged Now: Balance Charged Upon Completion: $ Date of Job: <br />Kevin Mears #02850 02/10/2021 <br />Hulett Representative Date Customer Signature <br />**Charge on your credit card statement <br />will appear as Hulett Environmental Services.** <br />w,wwv.bugg.cam <br />1-800-285-7378 <br />Date <br />SA007N 06/20 <br />Hulett Envirodrfrn7S—icc Q 2020 <br />