Credit Card Authorization Form -

461 Riverside Avenue Medford, MA 02155
(781) 395-3888 Fax (781) 395-0544

CREDIT CARD AUTHORIZATION FORM

Invoice/Quote#:*

Name:*

Address 1:*

Address 2:*

City:*

State:*

Zip:*

Phone:*

Mobile:*

Fax:

Email:*

Credit Card Type:* VisaMastercardAmerican ExpressDiscover

Credit Card Number:*

CID/CVV Code:*

Expiration Month:*

Expiration Year:*

Amount:*

Please indicate payment authorization for one of the following (check one and initial):* Single Purchase Authorization (Limits the amount to be charged to your credit card to the amount indicated above. Additional charges will require an additional signature.Blanket Purchase Authorization (Authorizes Beacon Electrical Dist. Inc. to apply charges, as indicated above, to your credit card, as well as any additional charges that may be incurred, without an additional signature. Additional charges may include, but are not limited to, freight charge(s) and/or additional or order placed via telephone or fax.

Initials:*

I authorize the use of my credit card for the purchase of electrical supplies/lighting fixtures and corresponding accessories as indicated above. I acknowledge Beacon's non-return policy for non-stock, special order items.

Please provide your signature:*

Type Signature Name:*

Attach Drivers License/ID (Acceptable file types- jpg|png|tiff|pdf|doc Max Size 1024mb):*

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