Auto-Pay Application Company Name *Street Address *City *State *Zip *Business Phone *FaxContact *Contact Phone *Email Address *Nature of Business *Year Business Began *Your Company is: *a Proprietorshipa Partnershipa CorporationGovernment-basedOtherPrincipal Owners or OfficersPrincipal Owner or Officer Name *Title *Home Address *Phone *0 / 14Principal Owner or Officer NameTitleHome AddressPhone0 / 14Authorized Purchasers / RentersPlease list persons authorized to rent and/or purchase equipment. (Applicant is responsible to periodically update list.)First NameLast NamePhone0 / 14EmailFirst NameLast NamePhone0 / 14EmailFirst NameLast NamePhone0 / 14EmailFirst NameLast NamePhone0 / 14EmailOwner/Officer Signature *Title *Date *Company Name *Type of Card *VisaMastercardDiscoverAmerican ExpressCard Number *Expiration Date *Verification Code *Phone *0 / 14Cardholder's Name as it Appears on Card *Authorized Signature *Type your name in here to sign this document.Credit Card Billing Address *Authorization ***By entering my name on this form as my signature, I authorize the billing of all transactions incurred at Equip Rental and Sales, LLC to the credit card listed above. I agree to all terms and conditions set forth by Equip Rental and Sales, LLC, and understand that all sales are final. By signing this agreement, I relinquish the right to dispute the charge.** A CERTIFICATE OF INSURANCE IS REQUIRED covering all rented equipment. Please list as follows: “Equip Rental and Sales, LLC. 420 S Church St, Saint Peters, Mo. 63376.” Equip Rental and Sales, LLC must be listed as "Loss Payee" and additional insured. Click HERE to view a COI form. EQUIP RENTAL EQUIPMENT PROTECTION PACKAGE (EPP)-Equip Rental can provide physical damage waiver coverage. If this is chosen, an additional cost will apply. This will eliminate your need to supply a Certificate of Insurance. The cost will be noted on the rental contract. You have the option to accept or supply coverage. EPP Guide To Submit: Phone: 636-355-8080 Fax: 636-355-8081Email: ar@equiprentalsales.comYour Signature *Send Message
