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Bank Card Authorization Form

BANK CARD AUTHORIZATION FORM

If you wish to pay by credit card, we accept Visa, Mastercard, American Express, and Discover.

Washer Specialties, Inc

I hereby order, and agree to pay for, goods/services and any special freight charges such as specific delivery appointments ($80.00), redelivery fees ($80.00), residential delivery fee ($80.00), or lift gate charges ($80.00) upon

invoicing from delivery company.


I authorize Washer Specialties Co., Inc to charge the following credit card

please put in your credit card number. Enter Credit Card Number *

CCV# *

Please use (mm/yy) format. Expiration Date of card *

Please fill in all required fields. Name *

Please use mm/dd/yy format. Today's Date *

Please fill in all required fields. Billing address on card *

Phone number for verification *

please enter your company name. Company Name *


Check the box if you would like us to keep your card number on file for future purchases.

Company Address *

Please fill in all required fields. Company Address (city, state, and zip code) *

Customer Number *

Amount of Payment *

Apply Payment to:

If Other please describe:

Remarks

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