CREDIT CARD PAYMENT FORM

 

We gladly accept Mastercard, Visa, Discover, and American Express.

 

Please print, fill out the form below, scan and email it Or, if you prefer, you may fax it to us at (678) 482-0771.  For added security, you may leave the credit card digits blank and call us at (678) 482-2910 with those.

 

 

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!