Sign and complete this form to authorize Hybrid-Kleen Solutions LLC to make a one-time debit to
your credit card listed below.
By signing this form, you give us permission to debit your account for the amount indicated on or
after the indicated date. This is permission for a single transaction only and does not provide
authorization for any additional unrelated debits or credits to your account.
I authorize the above-named business to charge the credit card indicated in this authorization
form according to the terms outlined above. This payment authorization is for the goods/services
described above, for the amount indicated above only, and is valid for multiple charges related to
housekeeping use only. I certify that I am an authorized user of this credit card and that I will not
dispute the payment with my credit card company; so long as the transaction corresponds to the
terms indicated in this form.