Uniform New Jersey Prescription Blanks Order Form (Page 3 of 3) in pdf

Uniform New Jersey Prescription Blanks Order Form Page 3

This credit agreement must be completed and returned with

your order forms in order to process your order

CREDIT CARD CHARGE

AUTHORIZATION AGREEMENT

I, ________________________________________________, the holder of (check one, please):

VISA

MasterCard

American Express

Discover

Card Number: ________________________________________________, Expiration Date: _____/_____

and the code that is on the back of your Visa, MC or Discover______________________.

I hereby authorize R. Press, Inc., as the parent company of Ridgewood , to charge my credit card

any invoice that I request. A $50.00 deposit will be charged to this credit card when the order is placed.

I also authorize Ridgewood to charge the above card in the occurrence of any shipping charges.

I have read this agreement and understand that I will be held fully responsible for its terms and charges

and agree not to chargeback Ridgewood as long as I have received the produces and services

that are defined within the term of the Ridgewood invoice.

Cardholder: ____________________________________________________________________________

Signature: ______________________________________________________________________________

Company: ______________________________________________________________________________

Mailing Address of Card: __________________________________________________________________

City, State, Zip of Card: ___________________________________________________________________

Telephone: (________) ___________________________________________________________________

Date: __________ /__________ /__________

Fax this completed form to our

Ridgewood Accounting Direct Fax: 201-670-9798

Uniform New Jersey Prescription Blanks Order Form Page 3