Credit Card Authorization Form

Welcome to the secure credit card authorization form.

IMPORTANT NOTICE ABOUT CREDIT CARD INFORMATION
Budget Video Rentals accepts payments from many sources including credit cards. For anti-fraud reasons we do NOT SAVE credit card information from any transaction to be used again on any future transaction. Each and every credit card transaction is the final use of that credit card number. It is NOT saved in our databases. This keeps the information away from hackers or prying eyes. It also avoids any errors since you, our customer, must agree on a specific figure in writing (on a new authorization submitted online, faxed, emailed, or by using the printed slip in our office).

STOP!

Before you fill out this form, use your camera phone, digital camera, or scanner to create four images:

- Front and Back of your Credit Card
- Front and Back of your Driver's License

At the end of this form, you'll be able to upload them and send them with your information. This MUST be done to validate your authorization!

NOTICE: Faxes and photocopies are NOT ACCEPTABLE


*required fields

Quote Number or Company Name

If you already created a quote, this will help us find it
  ESTIMATED Amount
$
 


*Name (as it appears on the credit card)
 

*Card Type
*Card Number (no dashes or spaces)
 
*Month
*Year
*CSC (what's this?)
 

Credit Card Bank information helps us protect you against fraud.
This information can usually be found on the back of the card.

Bank Name (on card)
Bank Phone (on card)
 


*Billing Address
 
*City
*State
*Zip
Country
 

Phone
Fax
Mobile
 
*Please fill in at least one contact phone number.

Email Address
 


I hereby authorize Budget Video Rentals to charge the above credit card for payment on this order, extensions of this order, and missing or damaged items.

*Digital Signature (what's this?)
*Date MM/DD/YYYY
 

Upload Images
Please attach your four JPEG images, in any order:
- Front and Back of your Credit Card
- Front and Back of your Driver's License






SUBMIT