Credit Card Authorization Form (Online)

CREDIT CARD PROCESSING AUTHORIZATION

I do hereby authorize Gulf Tire Distributors to process my credit/debit card as a method of payment for all outstanding invoices.

Company Name*

Credit Card Type

CC#

CVV#

Exp. Date

Credit Card Issuing Bank

Name as it appears on card

Credit Card Billing Address

City

State

Zip

Telephone #

Extension

E-Mail

Card Holder Signature

Date

Note: There will be a 4% Service Charge applied to all credit card payments.

*I do hereby Authorize GULF TIRE DISTRIBUTORS to charge my transactions to a credit card. I also authorize to charge my credit card for any event arose by NON-SUFFICIENT FUND (NSF) Check and refused order shipments (freight, special order, restocking fees). I understand the amount charged to my credit card will be reflected on my credit card statement within Seven days of Authorization. The amount charged is based on products or services requested by me or my company and prices quoted by a Gulf Tire Distributors employees or stated on www.Gulftire.net

NOTE: PLS INCLUDE A COPY OF FRONT AND BACK OF THE CREDIT CARD. THE BACK OF CARD MUST BE SIGNED, ALONG WITH COPY OF DRIVERS LICENSE. !! NO EXCEPTIONS !!!