PETER SAALMAN ASSOCIATES INC.

CREDIT CARD AUTHORIZATION FORM

 

Fax # 781-646-0123

                                                                                                             

DATE ______________________

 

ACCOUNT NAME _________________________________________________________________

 

D/B/A ___________________________________________________________________________

 

BUSINESS STREET ADDRESS ______________________________________________________

 

CITY_____________________________ STATE ________________ ZIP CODE _______________

 

TAX EXEMPT/ RESALE # _________________________________    

 

TEL. # ___________________________________ FAX # ___________________________________

 

EMAIL ADDRESS___________________________________________________________________

 

PLEASE COMPLETE THE FOLLOWING FOR CREDIT CARD PROCESSING:

 

TYPE OF CARD:  _____ VISA   ____ MASTERCARD   ____AMEX

                              _____ BUSINESS/CORPORATE      ____ PERSONAL

 

 

CREDIT CARD NUMBER ______________________________________________________________

 

EXPIRATION DATE ________________________SECURITY CODE (3 OR 4 DIGIT #) _____________

 

CARD HOLDER’S NAME (PLEASE PRINT):  ______________________________________________

 

 

CARDHOLDER’S SIGNATURE _________________________________________________________

 

IF DIFFERENT FROM ABOVE, BILLING ADDRESS OF CARDHOLDER’S CARD IS:

 

STREET # AND ADDRESS OR P. O. BOX # _______________________________________­­­­________

 

CARD HOLDER’S BILLING ZIP CODE ____________________________________________________