Credit Card Authorization Form

ONE TIME CREDIT CARD PAYMENT AUTHORIZATION FORM

Sign and complete this form to authorize Smardan Supply Co to make a one-time debit to your credit card listed below.

By signing this form, you us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account.

Please complete the information below:

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CC Type:

VisaMasterCardAMEXDiscover

Cardholder Name:

Account Number:

Expiration Date:

CVV (3-digit number on back of Visa/MC, 4 digits on front of AMEX):

Amount to be charged:

Invoice #:

Billing Address

Street:

City, State, Zip:

Phone#:

Email Address:

SIGNATURE OF CARDHOLDER:

Date:

I authorize Smardan Supply to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated on this form.

I have read and agree to the Terms and Conditions

Family owned and operated since 1930

www.smardan.com

810 E. Mason Street
Santa Barbara, CA 93103
PH: 805-963-8991
Fax: 805-966-3586
14009 Halldale Avenue
Gardena, CA 90249
PH: 310-532-5260
Fax 310-532-2567
17273 Mt. Hermann St
Fountain Valley, CA 92708
PH: 714-545-6912
Fax: 714-545-3496
257 Tank Farm Road
San Luis Obispo, CA 93405
PH: 805-543-0664
Fax: 805-543-0810
262 W Alameda Avenue
Burbank, CA 91502
PH: 818-845-2477
Fax: 818-955-8248