AC1 SUPPLY, INC
			CREDIT CARD INFORMATION SIGNATURE ON FILE 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 & DRIVER’S LICENCE 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 OR INTERNET. PURCHASES ARE NOT TO EXCED $:______________________ PER INVOICE. THIS AUTHORIZATION SHALL REMAIN IN FORCE UNTIL CANCELED BY ME IN WRITING TO THE ABOVE ADDRESS. I UNDERSTAND THAT A FAX COPY OF THIS FORM WILL BE CONSIDERED AS AN ORIGINAL BY AC1 SUPPLY, INC.
AUTHORIZED PURCHASER:
AUTHORIZED SIGNATURE OF CARD HOLDER:
			PLEASE RETURN BY FAX TO: (305) 556-6256
			AC1 SUPPLY, INC.

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