Mumpower Sign Supply Inc. Credit Card Charge Authorization Form Mumpower Sign Supply, Inc ______________________________________________________________________________________________________ Date:____________/_____________/______________ Company Name:________________________________________________________________________________________ Address:________________________________________________________________________________________________ City:___________________________________State:__________________Zip Code:___________Country:______________ Phone Number:______________________________________Fax Number:_________________________________________ Email Address:___________________________________________________________________________________________ I hereby authorize Mumpower Sign Supply Inc. to use my credit card for purchases made from Mumpower Sign Supply Inc. I understand that my credit card will be charged before goods will be released. All sales are final and non-refundable. Will this card be used for one time purchase only? _____Yes or _____No If Yes, total charge amount: US$__________________________ This card can be used for future purchases: _______________Yes or_______________No Please check one: __________Visa _________Master Card ___________American Express _____________Discover Card#:____________________________________________Card Code:____________Exp. Date (mm/yy):_________/___________ Print cardholder's full name as it appears on credit card:_____________________________________________________________ Credit Card Billing Address:____________________________Same as above or please write below: Address:____________________________________________________________________________________________________________________ City:____________________________________________State:_____________________Zip Code:_______________Country:______________________ Cardholder's Signature:________________________________________________________________________________________________________ The following persons are authorized to use this credit card on my behalf: ________________________________________________________ _________________________________________________________________ ________________________________________________________ _________________________________________________________________
I understand that I am obligated to notify Mumpower Sign Supply Inc. if there are any changes in the authorized users. I further understand and agree that my
credit card account will be charged in the event the card is used by formerly authorized users, unless I notify Mumpower Sign Supply Inc. in writing of changes
in the aurhorized users. Once an authorization has been made for a charge on my credit card account, Mumpower Sign Supply Inc. has the right to rely thereon
and I will not seek any reversal of credit card charges subsequent to their authorization. CARDHOLDER'S SIGNATURE attests financial responsibility,
willingness and ability to pay invoices in accordance with Mumpower Sign Supply Inc. Cardholder also acknowledges responsibility for any costs and expenses
incurred in collection of account by a third party. This authorization shall be renewed upon credit card's expiration.
Mumpower Sign Supply, Inc.
4257 Gate City Highway
Bristol, Virginia 24202
Phone (276)466-5943 * (1-800)368-5420 * Fax (276)466-5796 * (276)466-4751 * mumpowersignsupply.com
|