Credit Card Authorization Form

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Pleasecompleteallfields.Youmaycancelthisauthorizationatanytimebycontactingus.Thisauthorizationwill

remainineffectuntilcancelled.

Credit Card Information

CardType:

☐

MasterCard

☐

VISA

☐

Discover

☐

AMEX

☐

Other___________________________________________

CardholderName(asshownoncard):___________________________________________

CardNumber:___________________________________________

ExpirationDate(mm/yy):___________________________________________

CardholderZIPCode(fromcreditcardbillingaddress):___________________________________________

I,_______________________________,authorize__________________________________tochargemycreditcard

aboveforagreeduponpurchases.Iunderstandthatmyinformationwillbesavedtofileforfuture

transactionsonmyaccount.

______________________________________________ ______________________________________________

CustomerSignature Date

Landi Pool Service

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