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:
-----------------------
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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