Credit Card Account Authorization Form
(Please print information as it appears on your billing statement)
American Express - Discover - Master Card - Visa - (Circle one)
Card account number: ____________________________________________________
Expiration Date: _____ / _____ / 20___ Amount: $ ________________._____ (in U.S. dollars)
Name on card: ____________________________________________________________
Address: _________________________________________________________________
(As it appears on cardholder’s statement) NO P.O. BOX
_________________________________________, _________ - ___________________
City, State - Zip
Telephone number: (______) ________-_____________ Fax: ________-________________
Ad Pros Estimate/Quote number: ____________________ (Top right corner of estimate)
Company name: ____________________________________________________________
Print Name: __________________________ Signature: ______________________________ Date:____/____/____
Statement of Authorization: The purpose of this statement is to authorize Ad Pros of Palm Beach in West Palm Beach, Florida (also stated as the merchant) to process credit card transactions from the above stated applicant. These transactions will be processed via phone orders or in person at merchant location of business operation. By signing this document, I/we am/are accepting responsibility for these transactions to ensure full and proper payment to the merchant.
FAX TO 561-687-3711 TO PROCEED WITH YOUR ORDER ~ Thank You for Your Business!