GOLD RIVER DISTRIBUTORS



1120 Tara Court Suite 4

Rocklin, CA 95765

Ph: (916) 408-2226 Fax: (916) 409-9203

e-mail: info@

Authorization to Charge Credit Card

Business Name and Address___________________________________________________________________

Business Phone Number_________________________ Business Fax Number__________________________

Name As it appears On Card________________________________________________________________

Card Type_______ CID____ Card Account Number * Expires ___________

Card Billing Address_______________________________________________________________________

City________________________________ State________________ Zip Code________________________

Name As it appears On Card________________________________________________________________

Card Type_______ CID____ Card Account Number* Expires ___________

Card Billing Address_______________________________________________________________________

City________________________________ State________________ Zip Code________________________

1) All sales final 2) All orders plus shipping 3) Must have address of credit card holder on file

To: Gold River Distributors

The above information is true and complete. The signature listed below is my signature and the same as on my charge card. I understand and agree that all orders will be placed by myself, and I give Gold River permission to ship these orders to the above address and to charge these orders to the card number(s) listed above. This card may also be used to post a payment to my account that has not been received within my agreed payment terms.

Signed and Agreed _____________________________________ Dated: ________________________

I hereby certify that I have on file with Gold River Distributors, Inc., a copy of a valid State of ___________________ Resale Certificate and/or Seller’s Permit. When placing orders on this account, I will abide by the terms and conditions specified in the various catalogs and flyers of Gold River Distributors, including terms of payment. All purchases made through this account are made exclusively for business purposes and not for personal use. The undersigned must be at least 18 years of age.

Print Name_______________________________________ Date____________________________________

Signature ________________________________________

* Credit Card subject to usage fee - 2.5% -VISA / Mastercard, 3% - Discover/AMEX

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Dear Customer:

We are pleased to offer the use of credit cards for your convenience. We do, however, need a signed Authorization on file for charges other than those signed for on the premises. Please complete the enclosed AUTHORIZATION TO CHARGE CREDIT CARD form and return it to Gold River Distributors as soon as possible.

It is mandatory that an authorization be on file with us for your card to be processed.

Thank you for your prompt attention in this matter.

Sincerely,

Gold River Distributors

1120 Tara Court ( Suite 4 ( Rocklin, CA 95765

(916) 408-2226 ( Fax (916) 409-9203 ( Toll Free (800) 493-2306

( E-Mail

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