AC1 SUPPLY, INC

CREDIT CARD AUTHORIZATION

CARD No:

VISA

AMEX

MASTER

EXPIRATION DATE:

VALIDATION No:

Last 3 digits on the
Back of the card

A FAX COPY OF CREDIT CARD MUST ACCOMPANY THIS FORM

COMPANY NAME:

CARD HOLDER NAME:

CREDIT CARD BILLING ADDRESS:

CITY:

STATE:

ZIP:

TELEPHONE:

FAX:

IN COMPLITING THIS CREDIT CARD AUTHORIZATHION FORM I AUTHORIZE AC 1 SUPPLY, INC. TO PROCESS CHARGES TO MY CREDIT CARD FOR GOODS BEING SHIPPED OR PICK UP ON MY BEHALF ON THE BASIS OF ORDERS PLACED BY THE AUTHORIZED PURCHASERS MENTIONED BELOW VIA TELEPHONE OR FAX. I UNDERSTAND THAT A FAX COPY OF THIS FORM WILL BE CONSIDERED AS AN ORIGINAL BY AC1 SUPPLY, INC.

INVOICE/ESTIMATE No:

FOR $:

DATE:

AUTHORIZED SIGNATURE OF CARD HOLDER:

PLEASE RETURN BY FAX TO: (305) 556-6256

AC1 SUPPLY, INC.

6504 NW 77 th. Court, Miami, Florida 33166

Phone: (305) 556-6251