FAX TO: _______________________ (your move coordinator) FAX NUMBER: 925-371-0786

Credit Card Authorization Form

Select One: MasterCard/Visa Discover American Express

Today’s Date: __________ Order #: _______________ Estimate completed by: _____________________

Cardholder’s Name: ___________________________________________ Agent #: ___________________

Cardholder’s

Billing Address: ______________________________________________________________________________

Cardholder’s

Billing City, State and Zip Code: _______________________ Estimated Load Date: _____________________

Notice to cardholders: Please read before signing

Cardholder agrees that his/her signature on this form constitutes his/her “signature on file” and become his/her agreement to pay all charges as checked and signed by the cardholder and that United Van Lines is authorized to charge all such items to the identified account of cardholder.

Credit Card Number: __________________________________________________________________________

Expiration Date: __________ Business Phone: ______________ Home Phone: _____________________

 Non-binding Estimate + 10% of total:  Binding Total binding estimated charges:

estimates $__________________ estimates $_________________________

Cardholder signature: ____________________________________ Date: ____________________________

Note to Agency: Please obtain a separate authorization for auto shipments.

Order #: _________________________________________________

 Auto Estimated Cost of Service: Cardholder signature: (Sign and Date)

Shipments $____________________ ___________________________________________

Note to Agency: Please obtain a separate authorization for additional moving/supplemental expenses

The cardholder hereby authorizes the following estimated, additional moving/supplemental expenses. The actual moving expenses are the final audited costs of all services performed, including the original services requested and additional moving/supplemental services approved or requested by cardholder or otherwise required out of necessity. In the event that the final audited costs are in excess of the estimates, the cardholder shall be responsible for payment of the excess. In the event that the final audited costs are less than the estimates, which are charged to the cardholder’s account, the cardholder shall be entitled to a refund.

 Additional

Moving /

Supplemental

Expenses

Description of Additional Services: _______________________________________________________________

____________________________________________________________________________________________

I authorize United Van Lines to charge the above-referenced credit card account for the transportation and related charges on the household goods

move referenced above. I understand that the amount will be charged to my credit card account within approximately 48 hours of the load date.

Additional Moving Expenses: Cardholder signature: (Sign and Date)

$_______________________ __________________________________________________________________

Estimated additional moving expenses (total costs subject to final audit)