credit card authorization formtricountypump.net/wp-content/uploads/2015/11/ccauth... ·...
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![Page 1: Credit Card Authorization Formtricountypump.net/wp-content/uploads/2015/11/ccauth... · 2016-06-08 · Credit Card Authorization Form I/We authorize Tri County Pump Company to charge](https://reader033.vdocuments.mx/reader033/viewer/2022053001/5f05b4867e708231d4144a4a/html5/thumbnails/1.jpg)
Credit Card Authorization Form I/We authorize Tri County Pump Company to charge my credit account for charges incurred for the purpose listed below. I understand that I/We will be liable for all charges to this transaction. I agree to all listed purchases.
ITEMS TO BE PURCHASED
Description ______________________________________________________
______________________________________________________
Invoice # _________________________________
Total Amount _________________________________ plus freight and tax if applicable
CREDIT CARD ___Visa ___Master Card
Account Number _______________________________
Expiration Date _______________________________
CVV/ CCID Code _______________________________(3 numbers on back of card)
Name of Cardholder As it appears on the card _________________________________
Billing address of card _________________________________
Signature _________________________________________________
Date __________________________
Please fill in the above information. Once completed please fax the signed authorization form to Tri County Pump Company at (909) 888-3653.
By checking this box, you signify that your type name below constitutes your signature.
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