Credit Card Authorization

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Credit Card Authorization Form | Taylor PM Parts Program Form


(For better print use landscape layout)

Please print out and complete this form, then return it by FAX to 301-773-9872.

I hereby authorize Taylor Equipment Distributors, Inc. (Taylor AFS) to charge my credit card account for products or services as provided. Copies of all credit card transaction receipts will be provided.
All credit card information will remain confidential.

Location/BusinessName: ______________________________________________________________

Street: _____________________________________________________________________________

City: _______________________________________________________________________________

State: ______________________________________________________________________________

Zip Code: ___________________________________________________________________________

Telephone:( ) ________________________________________________________________________

Email: ______________________________________________________________________________

Fax Number:( ) _______________________________________________________________________

Credit Card: ( ) VISA ( ) MasterCard ( ) Discover Expiration Date: ______________________________

Name on Credit Card: __________________________________________________________________

Credit Card Number: ___________________________________________________________________

Security Code: _______________________________________________________________________

Credit Card Billing Address (if different from above):

Street: _____________________________________________________________________________

City: _______________________________________________________________________________

State: ______________________________________________________________________________

Zip Code: ___________________________________________________________________________

Telephone: ( ) ________________________________________________________________________

Fax Credit Card Transaction Receipt to Fax Number: ( ) _____________________________________

Cardholder’s Signature :_______________________________________________________________

Date: ______________________________________________________________________________

Cardholder’s Email: __________________________________________________________________

If you have any questions please contact Accounts Receivable at 301-773-2700.