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  • 1. Easy Rent Systems, Inc. FAX: 347-402-4900 CREDIT CARD AUTHORIZATION FORM Date 09/05/2013 I, Taylor Davis Hickman authorize Easy Rent Systems Inc. to charge my credit card listed below for the following services: Please place an “X” where indicated below to show us your authorization. SERVICE: Classic Advertisement X All Services under EASY RENT SYSTEMS Gold Advertisement Placement DIAMOND Advertisement Platinum Advertisement Placement POWER BOOST TIME Credit Card Holder (as appears on card) Taylor Davis Hickman Credit Card Number: 4235680033348432 Expiration Date: 08/16 Credit Card Holder Billing Address 4241 33rd Street, San Diego CA 92104 _______________________________________________________________________ Credit Card Holder Telephone # 619.346.2908 Email: taylordavishickman@gmail.com Credit Card Holder Signature: 9/5/2013 X Taylor Davis Hickman Taylor D. Hickman owner Signed by: Persona Not Validated - 1378405023248 This form authorizes the billing of this card for the following individuals or Accounts: AUTOMATIC RENEWALS**** If you wish for this authorization to continue automatically rebilling OR to use it for future renewals until you notify us, please write NONE in the END DATE column. Advertiser’sName Advertiser’sEmail Advertiser’s Phone Begin Date End Date** Greg Lobkowski realjock123@yahoo.com 619-8861638 Sept 5 2013 Oct 5 2013 Taylor D Hickman
  • 2. <realjock123@yahoo.com>; 4:14AM 4:13AM ***PLEASE COMPLETE THIS FORM AND RETURN IT TO US BY FAX OR VIA EMAIL AS A JPG OR PDF FILE***