Multiple Use Credit Card Authorization Form

If you agree to have your invoices billed directly to a credit card please complete this form in its entirety. We

will charge your card the invoice total and send the paid receipt to the email address you provide on this form.

Paying by credit card is a popular option and a great way to earn cash back, miles, points and other rewards on

your preferred credit card. We may already have this information on file but this form needs to be completed

with up to date information to ensure all expiration dates, verification codes and billing zip codes are current.

Fuel

Please note that if you wish GLM to put fuel in your boat at any time, we MUST hold a

valid credit card on file. Fuel charges will be billed automatically on the same day as fuel is supplied. We

have elected not to mark-up the per gallon cost of fuel, however due to the size of some of the larger fuel tanks

and the time they require to refuel, we do charge a labor fueling fee of $109 per hour, billable in quarter hour

increments, port to port, to account for the actual time spent fueling. 7.5% administrative & doc fees are

applied per invoice to offset the cost of credit card warehousing and ACH costs.

Credit Card Number: ______________________________________________________

Name on Card: ___________________________________________________________

Expiration Date: __________________________ Verification Code: ___________________

Email:_________________________________________________________________

Card Billing Address:_______________________________________________________

City:___________________________________ State:_________ Zip Code:___________

I authorize Grey Lady Marine, LLC to bill my above credit card (mark all that apply):*

[ ] All charges automatically, email paid receipt to the email above & provide a 5% fast-pay discount

[ ] All charges, subject to approval (please fax or email invoice to: ________________________)

[ ] Fuel only (cost of fuel + fueling fee noted above charged per each fueling)

*I acknowledge, agree and authorize that any outstanding balances for labor, parts, equipment, materials, supplies,

gas, fuel, fees, finance charges, etc. aged 60 days or greater will be automatically charged to the above credit card

unless the invoice is disputed in writing within fifteen (15) days of invoice issue date, regardless of the authorization

election. Failure or neglect to reply or dispute invoices in writing within the allotted time frame shall be deemed

ambivalent / complacent acceptance of all charges.

By completing this form and signing below, I authorize Grey Lady Marine, LLC to bill all charges as explained

above to my credit card.

Card Holder’s Signature: _________________________________________________

Multiple Use Credit Card Authorization Form - Grey Lady Marine