Credit Card Authorization Form Name TUFFLOK (a division of Altinex, Inc.) 500 Jefferson Street, Placentia, CA 92870 Sales: 990-2300 Fax: 990-3303 Visit Us: @www.tufflok.com Your completion of this authorization form will help us to protect you, our valued customer, from credit card fraud. All information entered on this form will be kept strictly confidential. Please complete the form below. Directions: If you have any questions, please call accounting at 714-989-2167. Thank you. Fill out this form completely. Credit card holders must digitally sign on the line indicated. We reserve the right to verify the provided information with your Credit Card issuing bank. Card Type: * Business Individual (personal) Company Name: Name on card: (First) * Last: * Credit Card type: * Visa Master Card American Express Discover Credit Card Number: * Security Code: * Expiration Date: * Credit Card billing address: * City: * State: * Zip: * Please Select Option: * This is a Personal Credit Card and I am authorizing to charge it for the purpose of a company purchase. This is a Business Credit Card and I am authorizing to charge it. Please Select Option: * I authorize TUFFLOK to charge this credit card for a specific order only. I authorize TUFFLOK to charge this credit card for current and future transactions until requested in writing to stop or an open credit limit has been established. Order #: Special comments: I understand the credit card authorization policy and authorize you to charge my credit card for the product(s) purchased. For customers with terms such as Net 30, the payment with a credit card after the product is shipped will incur a 3.5% service fee. I represent that the information provided in this Authorization is accurate, that the credit card is valid, and will not be declined. I agree to be bound by applicable policies, terms and conditions, and instructions for this transaction. Your Full Name (First and Last: * Email: * Phone: *
