LOS ALTOS SINGLE FAMILY FAMILY AUTHORIZATION RECURRING CREDIT CARD PAYMENT

First Name: *

First

Last

City: *

Authorized Signature *

Type your name below to digitally sign.

Authorized Signature (Optional for Joint Account) *

Type your name below to digitally sign.

Date

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email

Confirm Email

Service Address (if not the same as Billing address)

Address Line 1

Address Line 2

City

State

Zip Code

Daytime Phone Number *

Email

Confirm Email

PLEASE NOTE: Please allow seven business days for processing. Your account will be changed to autopay as of your NEXT invoice. Commercial customers will be processed monthly in arrears. Residential customers will be processed quarterly in advance. Open invoice(s) should be paid prior to your next invoice or all open invoice(s) will be added to your 1st autopay charge. Please notify Mission Trail if your credit card information changes.

Check this box if you would like to charge your credit card for any balance due on your account Mission Trail representative will con rm amount when processing your application.

If you are emailing this form DO NOT include your credit card information. Any applications received at Mission Trail via email with credit card information entered will immediately be deleted and your account will not be set-up for autopay. *

Customer/Account Name:

I (We) authorize Mission Trail Waste Systems, Inc. (Company) to initiate variable entries to my (our) credit card account. WE ACCEPT VISA, MASTERCARD AND DISCOVER. TO PROVIDE CREDIT CARD INFORMATION, PLEASE VISIT OUR OFFICE DURING REGULAR OFFICE HOURS OR WAIT FOR OUR REPRESENTATIVE TO CONTACT YOU BY PHONE. *

Weekday Phone Number:

RESIDENTIAL

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