Credit Card Authorisation Form



CREDIT CARD AUTHORISATION FORM

To Be Completed By Applicants - Please complete all sections and read the Terms and Conditions of Trade overleaf.

DATE: REF No ABN / ACN Number:

CLIENT’S TRADE NAME:

CLIENT’S FULL or LEGAL NAME:

Phone: Fax:

Mobile: Email:

Billing Address: Physical Address:

State: Postcode: State: Postcode:

CREDIT CARD AUTHORISATION

Visa Mastercard Amex Diners

Card Holders Name:

Card Number:

Expiry Date:

I authorise Fields Glass & Glazing Pty Ltd to arrange payment of my account by debiting my credit card account the number of which is specified above.

I acknowledge that Fields Glass & Glazing Pty Ltd may terminate this request at any time by written or verbal notice and I must adopt an alternative method of payment.

I have read and understand the GENERAL TERMS AND CONDITIONS OF TRADE (overleaf or attached) of Fields Glass & Glazing Pty Ltd which form part of, and are intended to be read in conjunction with this Credit Card Authority and agree to be bound by these conditions.

Cardholders Signature: Date:

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Fields Glass & Glazing Pty Ltd

ABN: 35 145 102 432 • Licence No. 228215C

18 Hunter Place, Castle Hill NSW 2154

Phone: (02) 9680 1900 • Fax: (02) 9899 6664

Email: sales@.au

Web: .au

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