33 West 17th Street * New York, NY 10011 *212-675-1900

Fax: 212-989-5018 www.lensandrepro.com

email:jklr@lensandrepro.com

CREDIT CARD AUTHORIZATION LETTER

Please complete this form and fax or email it back with a copy of the front and back of credit card and photo ID.

Please note we do not accept debit cards for collateral purposes.

Circle One: * Amex * Visa * Mastercard * Visa * Discover*

Credit Card Number:_______________________________________________ Exp. Date:_______

Card Holder Name: _______________________________________________________________

Credit Card Billing Address:_________________________________________________________

____________________________________________________________Zip_________________

Billing Telephone Number:_________ _________ __________________

Job Name:________________________________ Job PO or Job #:__________________________

I authorize (Please Print)____________________________________________to pick up or use this

equipment for me. Card holder signature_________________________________________________

I authorize Lens and Repro to use the credit card listed above for collateral, any damages, and/or payment related to my rental.

Cardholders Signature____________________________________

Date: _____________