DeHaven Camera Corp
5162 W. Jefferson Blvd., Los Angeles, CA 90016
Phone: (323) 555‑1234
Email: billing@dehavencamera.com
CREDIT CARD CHARGE AUTHORIZATION FORM
1. CREDIT CARD INFORMATION
2. PURPOSE OF AUTHORIZATION
By signing below, I (“Cardholder”) authorize DeHaven Camera Corp (“Merchant”) to charge the credit card referenced above for any of the following amounts incurred in connection with my rental and use of equipment and services:
1. Incidentals. Any miscellaneous charges (e.g. fees for late return, cleaning, additional accessories, shipping, rush service).
2. Loss or Damage Deductibles. Up to the stated deductible limits for repair or replacement of lost, stolen, or
damaged equipment.
3. Unpaid Balances. Any remaining balance owed for rental services, including overtime or extension fees.
Merchant will provide an itemized invoice or statement detailing any charges prior to submission to the card issuer.
3. TERMS AND CONDITIONS
1. Notification. Merchant will make reasonable efforts to notify Cardholder of pending charges via email or phone at least 48 hours before processing.
2. Disputes. Cardholder may dispute any charge by notifying Merchant in writing within 7 business days of the invoice date.
3. Security Compliance. Merchant complies with all applicable PCI-DSS standards for secure handling and storage of credit card data.
4. Validity. This authorization remains valid for the duration of the rental transaction and for up to 30 days thereafter to allow for final billing.
5. Revocation. Cardholder may revoke this authorization only by providing written notice to Merchant; revocation does not affect charges already processed under this authorization.
4. CARDHOLDER AUTHORIZATION
I certify that I am the authorized holder and signer of the credit card referenced above. I agree to pay the total amount according to the card issuer’s agreement. I have read and agree to the Terms and Conditions above.
