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SERVICE DEPARTMENT

Credit Card Payment Authorization Form

Customer Name*

For Inv # / Ref / Proposal #*

For one time payment / down payment: Minimum Service Call Charge is $540.00

For one time payment*

I, the undersigned being an authorized signor of the following account, hereby authorize Genset Services, Inc.

to charge to the credit card below for US$*

To be kept on file for future purchases/charges

To be kept on file for future*

I, the undersigned being an authorized signor of the following account, hereby authorize Genset Services, Inc. to charge to the credit card below for all future purchases or maintenance renewals as may be invoiced from time to time. I understand that I can always request to cancel this authorization on-file by providing a written request via email two (2) weeks prior to the effective date of this cancellation.

Credit Card*

Visa

MasterCard

AMEX

Credit Card Number*

Expiration Date (mm/yy)*

Security Code*

Name on Credit Card*

Billing Address of the Card*

Email address (to receive receipt):*

Job Site Name*

Job Site Address*

Date*

Print Name*

Phone #*

Please note there will be a 3% convenience fee added to the total for using a credit card for payment.

Please fax the completed information to (954) 968-6110, or you can send this as an email attachment to accountsreceivable@gensetservices.com

Genset Services, Inc.

ACH Bank Account

Branch Banking & Trust Co.

Account Number 0000246936579

Routing Number 263191387

Swift Code – BRBTUS33

Branch Address

110 E Broward Blvd.,

21st Floor Ft. Lauderdale,

FL 33301 Tel (954) 233-0554

Contact: Nicolas Jaramillo

Tel 954-233-0554

Email: njaramillo@bbandt.com

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