Credit Card Authorization
2335 STATE ROUTE 821 Marietta OH 45750
P: 740.568.9900 / F: 740.568.9399

Credit Card Authorization Form

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* Date: w 0

Today's Date:

Date

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* Company/Credit Card Information: w 0

Company:

Contact (placing order):

Phone:

E-mail:

Credit Card Type:

Credit Card Number:

CVV:

Expiration Date:

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* Billing Information: w 0

Cardholder Name:

Billing Street Address:

City / State/ Zip

ELPRO Quote or Invoice Number:

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* Ship To Information: w 0

Contact Name:

Shipping Street Address:

City / State/ Zip:

Phone Number:

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* Authorization: w 0

I give authorization to ELPRO Services, Inc. to charge the credit card listed above. For the purpose of recurring purchases and monthly rentals, ELPRO Services, Inc. reserves the right to charge this account without requiring the customer's signed authorization. I understand that credit card transactions incur a 3.0% transaction fee.

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* Shipping Information: w 0

Add shipping charges to my invoice

Use my FedEx shipping account

Use my UPS shipping account

Shipping Account Number