card - Carbiz

Accident Replacement Vehicle

Hirer Name*
Prefix First Middle Last
Hirer Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 Suburb State Post Code Country
Mobile Phone*
Email*
Replacement Vehicle - Make & Model*
Replacement Vehicle - Rego*
Referral*
Pre-Authorisation*
Price: A$ 100.00
Credit Card*
I agree to the credit card policy.
1. The Hirer authorises its credit card or any other card or account provided by the Hirer to be securely stored in stripe.com platform or a similar platform in accordance the Carbiz’s Privacy Policy.
2. The Hirer authorises Carbiz Rentals to:
  
  (a) charge to the credit card or any other card or account provided by Carbiz with any money due and payable by the Hirer under the Rental Agreement, including without limitation all payments referred to in Rates & Fees as well as payment for unauthorised use of the vehicle referred to in clause 3.18 or the Rental Agreement and payments for tolls, parking and traffic infringements and administration fees referred to in clause 6; and
  
  (b) put an authorisation hold on the amount of $100.00 from the available balance of the Hirer’s credit card or any other card as a security for the Hirer’s performance of its obligations under this Agreement.
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Consent
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Signature*
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