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Bank Card Authorization Form
 
BANK CARD AUTHORIZATION FORM
If you wish to pay by credit card, we accept Visa, Mastercard, American Express, and Discover.
Washer Specialties, Inc
I hereby order, and agree to pay for, goods/services and any special freight charges such as specific delivery appointments ($40.00), redelivery fees ($40.00), residential delivery fee ($40.00), or lift gate charges ($40.00) upon
invoicing from delivery company.
 
Enter Credit Card Number *
 
CCV# *
 
Expiration Date of card *
 
Name *
 
Today's Date *
 
Billing address on card *
 
Phone number for verification *
 
Company Name *
 
Company Address *
 
Company Address (city, state, and zip code) *
 
Customer Number *
 
Amount of Payment *
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