Credit Card Authorization Form

PLEASE PRINT CLEARLY

Date: __________

Buyer’s Name: _______________________

Credit Card: (Please Circle)                              MasterCard                  Visa

Credit Card Number: ____________________________________ Exp. Date: ________

I, ____________________________, hereby authorize Marisat Inc. T/A Auto Exchange to charge my credit card for the following:

_____________ Sale Price, Buyer Fee and Loading Fee          __________ Storage

_____________ Registration Fee         _____________ Misc. Fee

                                    Plus, a ____________ Handling Fee

Today’s Authorized Charge: ______________ (Includes a ________ Handling Fee)

Card Holder Credit Card billing address: _________________________________

                                                                        (Including Zip Code)

The last three digits of verification code printed on signature line on back of credit card (in reverse italic lettering): _________________

GENERAL WAIVER:  I am satisfied with the services/goods provided by Marisat Inc. t/a Auto Exchange and I understand that execution of this Credit Card Authorization Form constitutes a waiver of certain rights.  I hereby waive any and all claims, demand, actions, causes of action suits in equity of any kind or nature, past, present, or future, against Marisat Inc. T/A Auto Exchange including claims based on negligence of Auto Exchange or its employees. 

__________________________                                _____________________________

(Card Holder Signature)                                               (Daytime Telephone)

PLEASE FAX YOUR DRIVER’S LICENSE, YOUR CREDIT CARD, FRONT AND BACK, AS MENTIONED ABOVE AND YOUR BUYER ID CARD WITH THIS AUTHORIZATION FORM TO 732-238-9821

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