CREDIT CARD AUTHORIZATION
Please complete the following with your name and address as it appears on your credit
card statement. It is important that this information is correct, as we verify all
information with the credit card company for your safety.
Cardholder’s Name ______________________________
Billing Address ______________________________
City ____________________ State ______ Zip ____________
Telephone _______________ Fax ____________
Purchase Order Number ___________________________
Visa Mastercard Discover American Express
Credit Card Number ____________________________
Expiration Date ______/______
By signing below, I authorize ______________ to charge my credit card
$ ____________ (not including shipping charges)
Cardholders signature ___________________________ Date ____________
For office use only
Amount Charged $: Invoice Number: Charged
By:
Input Date: Sent By: Approved Date:
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