MX-126 CC Authorization Form

By completing and submitting this document, you have (i) agreed to honor your debt commitment entered
into via your signed contract by way of a credit card payment and (ii) authorized Piru Ranch MX LLC. to
charge your card the Credit Card Charge Amount set forth below. Once charged, you agree to honor your
obligation and agree to the terms set forth by your contract for:
Customer Name:
____ ________________________________
Cardholder Name and Billing Address:
_____________________________________
_____________________________________
___________________________________________
City:
______________________________________
State:
_________, Zip________________________
Phone: ______________________________________
Fax:
______________________________________
Type of Card (Please Circle)
AMX
Card Number:
____________________________________________________
Security Code :
____________________________________________________
Expiration Date:
_____________________
Credit Card Charge Amount:
$____________________
Credit Card Charge Amt
Payment For #
Cardholder Signature:
MasterCard
Visa
Amount
____________________________________________________________
Print or Type Name Clearly
____________________________________________________________
Written Signature
Date:
________________________________________________
This charge will appear on your statement as Piru Ranch MX LLC
PLEASE FAX THIS INFORMATION TO 818-700-0896
If you have any questions, please call 818-700-0878
21101 Osborne St, Canoga Park, Ca 91304