CREDIT CARD PAYMENT FORM

 

*A 3% credit card processing fee will be added to all orders paid with credit card.

We gladly accept Mastercard, Visa, and American Express.

Please print, scan and email it to us. For added security, you may leave the credit card digits blank and call us with them. 

 

PRINT TO PDF

 

 

Organization:________________________________________________


Bill to address on statement:________________________________________________


Person placing order:________________________________________________

 

Name on card:________________________________________________

 

Credit card number:_________ - ________ - _________ - __________

 

Expiration date:______ / ______

 

CVC/3 digit code on back of card:______

 

Signature:________________________________________________ 

 

 

Does your card have a per diem/transaction limit?  If so, what amount should we charge each day?  $________ 

 

If this is an official purchasing card with an individual code for it, please list it.  _________

 

 

 

 

Thank you for your order.

We appreciate the opportunity to serve you!