Locksmiths & Safemen Security Hardware Ltd

Credit Card Authorization Form

PLEASE PRINT OUT AND COMPLETE THIS AUTHORIZATION AND RETURN TO US. 
All information will remain confidential.

Cardholder Name:   ___________________________________________ 

Billing Address: ___________________________________________

___________________________________________

Credit Card Type: _____ Visa     _____ Mastercard    _____ AmEx

Credit Card Number: ___________________________________________

Expiration Date: ___________________________________________

Card Identification Number (last 3 digits located on the back of the credit card):  ________ 

Amount to Charge:  $  ________________ (CDN) 

I authorize Locksmith & Safemen Security Hardware Ltd to charge the agreed amount listed above to my credit card provided herein. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement.

Cardholder – Print Name, Sign and Date Below:

Signed: ___________________________________________

Dated: ___________________________________________

Name: ___________________________________________

 
Once signed return the completed form to:

Fax #: (905) 453-7840

Attn: Order Desk or Accounts Receivable if paying an existing invoice

Credit card authorization form courtesy of ServiceRelated.com