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Republic Services <br /> Credit Card Filling Authorization Form <br /> You have entered into a pre-payment agreement to pay for disposal services at Republic Services. <br /> Please complete this form,to enjoy the convenience of billing your credit card for disposal charges. <br /> Upon approval,your primary credit card(or alternate if the primary card is declined for any reason) <br /> will be billed for the amount due.To cancel this billing authorization,please call us at 209-466-4452. <br /> Cardholder Information: <br /> Cardholder's Name(Print or Type) Company Name(Print or Type) <br /> Home Phone Number Company Phone Number <br /> Email address <br /> Primary Credit Card(circle one) Alternate Credit Card(circle one) <br /> Visa/MasterCard/American Express Visa/MasterCard/American Express <br /> Cardholders Name(as it appears on card) Cardholder's Name(as it appears on card) <br /> Billing Address(Street,Apt#Suite) Billing Address(Street,Apt Suite) <br /> City,State,Zip Code City,State,Zip Code <br /> Credit Card Number Credit Card Number <br /> Card Security Code Card Exp,Date Card Security Code Card Exp.Date <br /> -------------- <br /> Cardholders,Signature Today`s Date Cardholder's Signature Today's Date <br /> I authorize Republic Services to bill one of the credit cards listed above as specified below: <br /> I understand that my credit card will be billed daily for the balance on loads taken in to the Republic Services.(Initial) <br /> Note: Should both credit cards be declined for any reason,loads brought to Republic Services will <br /> not be permitted to use the facility,until a blank check,payable to Republic Services,is <br /> provided to pay for the disposal fees. <br /> This authorization form applies to Republic Services only. <br /> Please fill out and return by fax 209-466- � ' <br /> APR 0 8 205 _ <br /> EN�IRONMENTA�` <br /> HEA- <br />