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2. AUTHORIZATION AND RELEASE FOR CREDIT CARD USE, (Fuel, oil and pilot supplies)
4. Name as it appears on card:
6. Credit Card Type
   -- Select One --VisaMastercardAmerican ExpressDiscover
7. Phone
9. Credit Card Number:
11. Expiration Date:
12. Email
14. A copy of the above referenced credit card is attached to the Authorization and Release. Charges may be made on said card for the following aircraft:
    (list each aircraft tail number and type)
16. In addition to myself, I authorize the following persons who may make purchases using the above credit card information:
    (list each name)
18. In consideration of the airport making this credit option available to me, and understanding that while every effort will be made to keep this information confidential, but realizing the potential for unauthorized use, I do hereby, for myself, my heirs and representatives, release, waive and covenant not to sue, hold harmless and forever discharge the employees, agents, officers, administrators, and representatives of the city of Mesquite and Mesquite Metro Airport, from any and all liability, claim, demand, damage, action or right of action of whatever nature arising out of the use of the above described credit card.
20. Select one of the following in reference to the above statement:

    1. I agree
    2. I disagree
22. This authorization and Release shall remain in full force and effect until the earliest of the credit card expiration date or such time as it is revoked by me or my legal representative in writing.

    1. I understand
    2. I do not understand
24. First Name
25. Last Name
27. Address1
28. City
30. Zip
31. Signature
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field