Orpheum Parking Lot CREDIT CARD AUTHORIZATION

Name: ________________Account Number: _____________ Email:_______________

Billing Address:________________ City:_________State:____ Zip:_______________
Business Address:_______________ City:_________State:____ Zip:_______________
Home Phone:____________ Business Phone: ____________Fax: __________________
Vehicle
Make:

Vehicle
License:

Drivers
Lic. No.:

Parking to commence: January 01, 2015

I hereby authorize Allied Parking, Inc. to charge my credit card on a monthly basis for
parking charges incurred each month. Credit cards will be charged between the first and
the fifth of each month.
Credit Card
Visa

M/Card

AMEX

Expiration Date

Discover
Last 3 digits

Card Number

Amex Number

on back of card

Valid Date
Signature/ Authorization

Date
It is the customers responsibility to cancel the authorization with their credit card company upon
proper notification to Allied Parking, Inc. of their termination of parking. If the customer fails to
do so, the liability of Allied Parking, Inc. is limited to a maximum refund of two (2) months
parking payments.
All rejected transactions carry a $25.00 administrative fee.
This agreement is subject to the Parking Agreement (Lease) for the Centre Village Ramp.

I ACCEPT AND AGREE TO THIS MONTHLY PARKING AGREEMENT WITH Allied Parking, Inc.. I ACKNOWLEDGE
THAT I HAVE READ AND AGREE TO THE TERMS AND CONDITIONS LISTED ABOVE, AS WELL AS THE
MONTHLY PARKING AGREEMENT (LEASE) FOR THE CENTRE VILLAGE RAMP.

SIGNATURE/ AUTHORIZATION:______________________

DATE: _______________