DD# _________
A TOE TRUCK
A DIVISION OF “WEST VENTURES INC”
P.O BOX 3142
PARKER, AZ. 85344
CORP OFFICE: 928-669-5600
FAX: 928-667-1968
Toe Form 114 7/23/14jr
CREDIT CARD AUTHORIZATION FORM
Please submit a completed credit card authorization form, make a legible photo copy of the credit card and
customer driver’s license (front & back). All costs for goods and or services as indicated in your Agreement,
Addendums, Service Order Confirmations or other documents, that are incurred before, during or after your event
will be charged to the card listed below.
Name on Card: (PRINT) __________________________________________________________________________________________
Drivers License Number: _________________________ State: _________________ Date of expiration ______________________
Credit Card Number: __________________________________________________________________________________________
Expiration Date: ___________________ V-Code: ____________
Credit Card Type: Debit Card _________ Discover __________ Master Card __________ Visa ___________
Billing Address: __________________________________________________________________________________________
City, State, Zip: __________________________________________________________________________________________
Phone Number: _______________________________ Fax Number: ________________________________
I the undersigned cardholder, hereby authorize my credit card to be used as indicated here.
Printed Name: _________________________________________________
Cardholder signature: _________________________________________________ Date: ___________________________________
Send a copy of your Drivers License along with copy of front and back of the Credit Card
to atoetruckdispatch@yahoo.com
FOR INTERNAL USE ONLY:
West Ventures Inc. is an Arizona S-Corporation doing business as A Toe Truck
GOVERNING LAW: The terms of this Agreement shall be constructed in accordance with the governing law of the State of Arizona, County of La Paz.
Call Number: ____________
Type of Service:
_____________________________________________________
Location of Service:
______________________________________________________________
Service Date: _________________
Processed by: __________________________________ Initialed By: ________________
(Print Name)
Amount Authorized: $ _______________ Authorization Number: _____________________
