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.

I authorize Washer Specialties Co., Inc to charge the following credit card


Enter Credit Card Number *


CCV# *


Expiration Date of card *


Name *


Today's Date *


Billing address on card *


Phone number for verification *


Company Name *

Check the box if you would like us to keep your card number on file for future purchases.

Phone: 316 263-8179 or 800 835-1010, Fax: 316 263-2040 or 800 835-1150
224 Indiana, Wichita, Ks 67214
8:00 AM to 5:30 PM M-F, 8:00-Noon on Saturday, Closed on Sundays and Holidays.
Tempstar Distributor for Kansas