Submission Form - Emsl Analytical Page 3
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UTHORIZATION
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By signing this form and providing your credit card number, you acknowledge that the card # and
information on the card is valid and was not obtained fraudulently. You authorize EMSL to
receive payment for analytical services from the credit card company contemporaneous with the
invoice(s). Any disputes regarding quoted prices, results or other testing issues must be
submitted in writing to EMSL management for resolution within 30 days of invoice date. Contact
customer service at 1-800-220-3675 for the address. Our policy is to offer in- house credit only for
analytical results provided by EMSL under the terms negotiated; cash refunds may be issued on a
case by case basis. Cardholder is responsible for updating credit card information as necessary.
Important Disclaimer
EMSL Analytical, Inc. is committed to a security standard policy that protects your credit card data from
unauthorized access once this data is in our possession. EMSL does not guarantee the security of your
credit card data during the period of transmission (i.e. mail or FAX).
_____________________________________
_______________________________________
Company Name: (if applicable)
Name on Credit Card:
Visa
Master Card
American Express
____________________________
______/_______
Card Number:
Exp Date (MM/YY)
___________________________________________
_____________
________________
Credit Card Billing Address
State/Province
Zip/Postal Code
____________
Security Code
_________________________________________
______________________________________
Cardholder Signature
Cardholder Phone Number
For EMSL Use Only:
_______________
___________________
$___________
_____________________
Customer Number
Invoice or Order Number
Invoice Total
Date
______________________________________
_________________________________________
Credit Card Charged by: (Print Name)
Credit Card Charged by: (Signature)
Comments:
______________________________________
Credit Card Authorization Code
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Controlled Document – Misc. COC R9 -5/12/2016
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