Portable Toilet Rental
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I,(Above Individual), allow Brunson Pump Service to charge my credit/ debit card or bank account below for any current and past due balances owed on my account as of (Date Below), or every 28 days starting date below.

Goods and Services provided:
  • Portables/Island Sinks
  • Dumpsters
  • Temporary Fencing
  • Fresh Water/Waste Water Holding Tanks
  • Storage Containers
  • Mobile Offices
  • VIP Trailers
  • One Time Charge: Please sign and complete this form to authorize a one-time charge to the credit/debit card or bank account below for any balances oweed or damages.
  • Recurring Charge: You authorize Brunson Pump Service to charge the credit/ debit card or bank account listed below periodically (every 28 days) In each billing cycle, you will be charged the base amount for the rental, taxes and a 3% credit/ debit card fee. You will be sent an email/paper receipt for each payment and the charge will appear in your bank statement as Brunson Pump Service

In the event that the billing date or amount charged changes, you will be notified of such change.

Address

Credit Card Information

Type
Card Holder's Name