Credit Card Authorization Form

Credit Card Authorization

CREDIT CARD AUTHORIZATION FORM

Altinex Inc.
500 Jefferson Street, Placentia, CA 92870
Sales: (714) 990-2300 Fax: (714) 990-3303
Visit Us: @www.airgap.com

Completing this authorization form will help us protect you, our valued customer, from credit card fraud. All information entered on this form will be kept strictly confidential. Please complete the form below.

If you have any questions, please call our accounting department at 714-989-2167.

Please complete this form thoroughly. The credit card holder must digitally sign on the line indicated. We reserve the right to verify the information provided by your credit card issuing bank.

Card Type:

Business

Personal

Company Name:

Name on the card: (First)

Name on the card: (Last)

Radio Field

Visa

Master Card

American Express

Discover

Credit Card Number

Expiration Date:

CVV:

Credit Card billing address:

City:

State:

Zip:

Please Select Option:

This is a Personal Credit Card and I am authorizing to charge it for the purpose of a company purchase.

This is a Business Credit Card and I am authorizing to charge it.

The Altinex Sales Order #:

Special Instructions (Optional)

I understand credit card authorization policy and hereby authorize to charge my credit card for the product(s) purchased. For customers with terms such as Net 30, the payment with a credit card after the product is shipped will incur a 3.5% service fee.

I represent that the information provided in this Authorization is accurate, that the credit card is valid, and will not be declined.

I agree to be bound by applicable policies, terms and conditions, and instructions for this transaction.

First and last name:

Email

Phone: