Credit Card Agreement - American Agroproducts
American Agroproducts, Inc.
Credit Card Authorization Form
Fax to: 214.951.7839
Business Name: ________________________________________________________________
I am an authorized signer on the following credit card account. I authorize American Agroproducts, Inc. “AAI” to charge the amount below on the following credit card for payment of merchandise received by me and/or my business.
A copy of this credit card must be on file or faxed with this form. If a copy of the credit card is not made available, the charge will not be made. Finance charges of 18%APR may be assessed on AAI past due accounts.
Credit Card Type: (circle one) Mastercard Visa American Express
Credit card number on file: __________________________________ # on Reverse __________
Expiration date on card: _____________________
Name Printed on Card: ___________________________________________________________
Authorized Amount of Charge: (check one below)
❑ I authorize a one-time charge of $_____________ to the above-listed account for payment of merchandise received.
❑ I authorize charges to the above-listed account for payment of merchandise received, including past due amounts, up to the total amount of $ __________________ per charge, until I provide American Agroproducts, Inc. with written notice that charges will no longer be authorized. If no dollar amount is written in the space above, I authorize any charges up to the maximum credit available limit on the above-listed account.
❑ If no dollar amount is written in the space above, I authorize any charges up to the maximum credit available limit on the above-listed account.
Authorized Signer on Card must sign below to approve this charge to be made. Authorized signer agrees to pay the amounts printed and written above by charges to the credit card listed above. Signer understands that signer is responsible for full amount owed, should this agreement be found invalid for any reason. Signer understands that if charges are successfully disputed, signer will be responsible for the amount above plus any finance charges, collection fees, attorney fees and/or court costs incurred in attempting to collect the debt owed to AAI.
I understand and agree to the above terms. I authorize American Agroproducts, Inc. charge the above credit card for the amount stated above, on or after the date specified.
Signature: ____________________________________________________________
Print Name & Title: _____________________________________________________
Address: ______________________________________________________________
Phone: _________________ Fax: ____________________ Other: ______________
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