Credit Card Authorization - Fall Fittings, Inc.

Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by

contacting us. This authorization will remain in effect until cancelled.

Credit Card Information

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Single Use Payment Information

(Leave Blank if this is an automatic charge authorization)

Total Payment Amount:

Total

Please list Invoices to be paid:

Frequency:

Daily after each shipment for entire shipment amount

Monthly for entire account balance on ___________ day of month

Day of Month(Required)

Automatic Charge Information (Leave Blank if this is a single use authorization)

Please note: A 3.5% processing fee will be applied

Signature(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date(Required)