Credit Card Authorization Form

Dear Valued Customer,

Please confirm that the following information is accurate and you are a willing participant in United Roofing Supply® charging the following credit card. In addition, you acknowledge that no discount will be offered when paying via credit card.

Date:

Customer Name:

Customer Account Number OR Invoice Number:

Tax Exempt:

YES NO

Tax Amount:

Total Amount:

Type of Credit Card:

Credit Card Number

Expiration Date:

Security Code (on back of card):

Name on Credit Card:

Billing Address of Credit Card Statement:

I.D. Verification / Driver License #:

If you agree with the above information,please sign below and fax back to: unitedroofingsupply@gmail.com

We ask that a copy of your driver's license and the front and back of the credit card be included with the authorization form. Please be assured that this information will be kept in a secure file to ensure this information is kept confidential.

Signature of Card Holder: