Credit Card Authorization Form

J. B. Parks Wholesale Florist, Inc.
CREDIT CARD AUTHORIZATION FORM
I, ___________________________________________________
authorize J. B. Parks Wholesale Florist, Inc. to charge orders
to the credit card account listed below. I authorize this credit
card to be used for daily invoices or monthly statement charges
unless notification by the below signed is given to the office
manager, Bobbie Black only. I certify that the credit card
account is valid. I also agree to notify J. B. Parks Wholesale
Florist, Inc. when specific information changes regarding the
validity of this credit card. If you wish to have a limit of an
amount charged to this card, please let us know the amount:
$______________. If this credit card account is deemed invalid
while attempting to complete payment for an unpaid delivery, I
agree to send payment immediately upon notification, or
provide a valid credit card.
_______________________________
Shop Name
_______________
Account Number
_______________________________
Credit Card Number
________________
Expiration Date
____________________________________ ________________
Card Holder’s Name
Today’s Date
_____________________________________________________.
Card Holder’s Address (where credit card bills are sent)
_____________________________________________________.
Authorized Signature
Title
Please fax completed form to: 214-821-6460