Credit Card Authorization Form

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Plant # : 
Customer #:  
8750 North Central Expressway Suite 1800, Dallas, TX 75231
Phone: 214-272-4157
Credit Card Authorization Form
- Confidential -
Company Name:
Name On the Card:
Card Holder Billing Address:
Telephone #:
Fax Number:
City / State / Zip
Email Address:
Credit Card Type
Credit Card Number
Expiration Date
Please Select one of the Following Billing Options:
This is a one (1) Time Authorization. Please only charge my card one (1) time for the following invoice / amount:
Invoice # _________________ / Invoice Date: ____________________ Invoice Amount ___________________
This is an on-going authorization until such time as it is revoked in writing. Accordingly, I understand that my card
will be charged at the time of delivery for product(s) delivered and / or services rendered.
I hereby authorize Reddy Ice Corporation to charge the aforementioned credit card for service rendered and / or product delivered.
I agree to pay for this purchase and to abide by the cardholder agreement. I also agree to hold Reddy Ice Corporation harmless
against any liability pursuant to this authorization. This authorization will remain in effect until such time as it revoked in writing.
Authorized Signature:
Contact Phone:
Printed Name / Title:
Date Signed:
Please fax or email the completed authorization form to:
Fax: 1-866-276-0463 - Email:


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Parent category: Business