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Credit Card Authorization Form

Home Credit Card Authorization Form

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Customer Name

Customer Acc #

Credit Card #

EXP Date

Security Code

Type of Credit Card

VISA

Mastercard

American Express

Discover

Name of Credit Card Holder

Credit Card Billing Address

Email Address

Phone Number

Sales Order or Invoice Number(s)

Charge Amount $

3% surcharge $

Total $

Please note that all credit card transactions will be subject to a 3% surchage. All credit card transactions must be signed off by a company officer or authorized personnel:

Person Authorizing Charge:

Print

Signature

Date

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510 N Turkey Creek Rd, Plant City, FL 33563

813.659-2709

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