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First Name:
Last Name:
Billing Address:
City:
State
Zip Code:
Same as Billing Adddress
Shipping Address:
City:
State
Zip Code:
Phone Number:
E-Mail:
I (Cardholder) hereby authorize my credit card to be charged the payment amount as indicated herein for the relocation of my household goods under the order number listed above. I fully understand that my payment is nonrefundable. If payment is for the deposit required at the time of reservation, a cancelation notice must be provided in writing as per the cancellation policy listed on my estimate; If payment was made for the pick up or delivery portions of my relocation service, I understand that any and all disputes between me and the carrier a claim must be filed in writing within 9 months of the date of the delivery as indicated in section eight (8)- Filing of Claims of the Terms and Conditions on the Bill of Lading governing my move.”
Amount: