CREDIT CARD AUTHORIZATION FORM: Fill out and fax to (773) 880-6647

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CREDIT CARD AUTHORIZATION FORM: Fill out and fax to (773) 880-6647

Credit Card Authorization Form
Please print, fill out, and fax to 1-800-99FAXUV (800-993-2988) or (773) 880-6647.
This form authorizes UV Process Supply, Inc. to charge the card holder’s credit card for payment of this confirmed order. Credit Card Authorization forms are secured in the Accounts Receivable Office for your safety.

Bill To Address

Company Name:

Address:

City:

State/Province:

Postal Code:

Country:

Phone:

Fax:

Email:

***Credit Card Billing Address***
(may be different than Bill To Address above)
NOTE: It is very important that you supply us with the billing address that is on your credit card billing statement.
Otherwise, we are not able to obtain the proper authorization for your credit card.

Address:

City:

State/Province:

Postal Code:

Country:

Cardholder Name:

Cardholder Phone:

Credit Card Type: Visa MasterCard American Express

Credit Card Number:

Please include the security number
as shown to the right: _______
Expiration Date: _________

Signature:

Check here if you would like to keep your credit card information and signature on file for future orders.

Ship To Address (if different than Bill To Address)
Company Name:

Address:

City:

State/Province:

Postal Code:

Country:

Phone:

Fax:

Please return the completed form to UV Process Supply, Inc. Accounts Receivables at:
Fax: (773) 880-6647
Phone: (773) 248-0099