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Credit Card Authorization

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CREDIT CARD INFORMATION

NAME ON CREDIT CARD *

TYPE ON ACCOUNT

PERSONAL
BUSINESS

COMPANY NAME

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CREDIT CARD NUMBER

EXPIRATION NUMBER

CV/SECURITY CODE

BILLING ADDRESS

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CITY

STATE

ZIP CODE

PHONE *

FAX

EMAIL *

AUTHORIZATION USER OF CARD

Name *

First

Last

COMPANY

PHONE NUMBER

AUTHORIZATION OF CARD USE

I certify that I am the authorized holder and signer of the credit card referenced above.

I certify that all information above is complete and accurate.

I hereby authorize collection of payment for all orders placed with Zone Wholesale

CARDHOLDER NAME *

DATE

Credit Card Images *

Click or drag files to this area to upload. You can upload up to 3 files.

Please upload a front and back picture of the card on this form.

SIGNATURE *

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