Credit Card Holders Full Postal Address

Post Code

Credit Card Number

Your Card’s Security Code *

Valid From

Expiry Date

Equipment Description Summary:

Hire Charge

£

Total Carriage

£

Sub-Total

£

Credit Card Surcharge (3%)

£

V.A.T.

£

Deposit

£

TOTAL

£

* On most Credit Cards, this is the three digit number on the reverse of the Card

I authorise Easirent Limited to charge the above amount to my Credit Card as described.

Signature

Print Full Name

Date

THIS FORM MUST BE SIGNED BY A DULY AUTHORISED PERSON IN THE COMPANY.

• Upon Return of the Equipment, a refund will be issued by Easirent Limited subject to its Terms and Conditions, for the remaining deposit value.
• I understand that I must arrange for full insurance, for the total value of the equipment.
• Weekly contracts are extendible on weekly basis only and monthly contracts are extendible on monthly basis only.

I have read and understood Easirent Limited’s Terms and Conditions and agree to enter into a rental contract based on these.

Print Full Name

Date

THIS FORM MUST BE SIGNED BY A DULY AUTHORISED PERSON IN THE COMPANY.