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RUST AUTO SHIPPERS, Inc.

272A Ocean Road, Greenland, NH 0384

(800) 331-3496 * (603) 430-6082 FAX

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CREDIT / CHARGE CARD RELEASE FORM

I authorize Rust Auto Shippers, Inc. (R.A.S.) to charge my credit account identified below, for the transportation of my vehicle(s)

Origin:_____________________Destination:_____________________

                                (City & State)                                                                        (City & State)

CARDHOLDER’S NAME____________________________________(Please Print)

(Circle One)               VISA     **    MASTERCARD   **  DISCOVER

CARD #:______-_______-_______-_______EXP.:M______Y_____

Charge my account the amount indicated    $_________                    

CARDHOLDER'S INITIALS_________    Security Code #:_____________             

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CARDHOLDER’S SIGNATURE                             DATE

_____________________          ____________________

_____________________          ____________________

     (Address as appears on billing)                             (Address for mailing Receipt)

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Please fill in and sign the above form and FAX back to RAS at (603) 430-6082