Credit Card Authorization Form printable pdf download

Credit Card Guarantee of Payment

Blanket Authorization Form

Customer Name:

______________________________________________________

Facility or Location: ______________________________________________________

Shipping Address if different from billing address below*

Address: _______________________________________________________________

City: __________________________ State: _______________ Zip: ____________

* For multiple shipping addresses with the same credit card please complete a form for each shipping address.

Credit Card Information

□ Visa

□ Mastercard

Card Type:

Cardholder(s) Name: ___________________________________________________

As it appears on your card

Address: _______________________________________________________

As it appears on the Credit Card Account

City: __________________________ State: _______________ Zip: ____________

Credit Card Number: _____________________________ Cid # _______________

Last 3 digit number on the back of your card

Expiration Date: _______________

I hereby authorize delivery of product to the shipping address above which may

not be the credit card billing address. I agree that I will pay for this purchase and

indemnify and hold Phoenix Wholesale Foodservice harmless, against any

liability pursuant to this authorization. I understand that my signature on this form

along with a copy of my credit card and a picture I.D. will serve as my authorized

signature on credit card charge slips. I understand and agree to the terms and

conditions as outlined on the invoice. I also authorize product to be left at my

credit card billing address and/or other shipping address without obtaining a

signature on a credit card charge slip. I agree that Phoenix Wholesale

Foodservice is not responsible for purchases that are late, lost or stolen if I or my

designated recipient does not sign for a purchase for any reason. And I hereby

authorize Phoenix Wholesale Foodservice to charge the credit card noted for

payments of fees, costs, and expenses which are incurred by me or any member

or employee of my professional organization stated above. I certify that I am

authorized to sign this form on behalf of this organization. I understand that

charges will be made to this credit card account and if the credit card is declined

for any reason I will be responsible for payment of any outstanding charges and

fees resulting from the declination.

Signature: ___________________________

Date: _____ / ______ / ______

Corporate / Templates / Credit card authorization form / 1/8/2013

Credit Card Authorization Form