Credit Card Authorization Form
Anaheim 1005 Edward Ct. Anaheim, CA 92806 T: 714.688.2560 F: 714.688.2570
San Diego
Hawthorne
1004 Cudahy Pl. San Diego, CA 92110 T: 619.275.8700 F: 619.275.8710
4828 W. 145th Street Hawthorne, CA 90251 T: 310.349.5100 F: 310.349.5110
Sylmar
West LA
Riverside
16348 Foothill Blvd. Sylmar, CA 91342 T: 818.403.2000 F: 818.403.2010
2311 Purdue Ave. Los Angeles, CA 90064 T: 424.276.4200 F: 424.276.4210
1886 Spruce Street Riverside, CA 92507 T: 951.384.4800 F: 951.384.4810
www.toddpipe.com
CREDIT CARD AUTHORIZATION Form/Agreement for On Account Customer Account Name: 1 I hereby authorize Todd Pipe & Supply to charge my credit card (Visa,/Mastercard/American Express on this date, ____/____/ 20___ 2 I understand by using my credit card, I agree that I am not entitled to the any discount 3 The total charge to my credit card including all taxed and other charges will be: $______________ Name as it appears on Card:___________________________________________ Billing Address:______________________________________________________ ______________________________________________________ Phone Number:______________________________________________________ Email/Fax Number for receipt:_________________________________________ Credit Card: (check one)
Visa
MasterCard
American Express
Credit Card Number:__________________________________________________ Expiration Date:_________________________________________ (month/year) Verification Code:______________________________ (3 digits on back of card) American Express Code:________________________ (4 digits on front of card) Signature of Card Holder:___________________________ Date:_____________ Todd Pipe & Supply LLC Confidental Notice: The transmitted documents are intended only for the use of the individual or entity to which they are addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipent, you are hereby notified that any dissemination, distribution or copying of the documents transmitted with this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone so that arrangements may be made to return the original documents to us.
San Diego
Hawthorne
1004 Cudahy Pl. San Diego, CA 92110 T: 619.275.8700 F: 619.275.8710
4828 W. 145th Street Hawthorne, CA 90251 T: 310.349.5100 F: 310.349.5110
Sylmar
West LA
Riverside
16348 Foothill Blvd. Sylmar, CA 91342 T: 818.403.2000 F: 818.403.2010
2311 Purdue Ave. Los Angeles, CA 90064 T: 424.276.4200 F: 424.276.4210
1886 Spruce Street Riverside, CA 92507 T: 951.384.4800 F: 951.384.4810
www.toddpipe.com
CREDIT CARD AUTHORIZATION Form/Agreement for On Account Customer Account Name: 1 I hereby authorize Todd Pipe & Supply to charge my credit card (Visa,/Mastercard/American Express on this date, ____/____/ 20___ 2 I understand by using my credit card, I agree that I am not entitled to the any discount 3 The total charge to my credit card including all taxed and other charges will be: $______________ Name as it appears on Card:___________________________________________ Billing Address:______________________________________________________ ______________________________________________________ Phone Number:______________________________________________________ Email/Fax Number for receipt:_________________________________________ Credit Card: (check one)
Visa
MasterCard
American Express
Credit Card Number:__________________________________________________ Expiration Date:_________________________________________ (month/year) Verification Code:______________________________ (3 digits on back of card) American Express Code:________________________ (4 digits on front of card) Signature of Card Holder:___________________________ Date:_____________ Todd Pipe & Supply LLC Confidental Notice: The transmitted documents are intended only for the use of the individual or entity to which they are addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipent, you are hereby notified that any dissemination, distribution or copying of the documents transmitted with this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone so that arrangements may be made to return the original documents to us.
