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 ($80.00), redelivery fees ($80.00), residential delivery fee ($80.00), or lift gate charges ($80.00) upon invoicing from delivery company.

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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*

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

Company Address*

Company Address (city, state, and zip code)*

Customer Number*

Amount of Payment*

Apply Payment to:

If Other please describe:

Remarks