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Dirt Cheap Pipes CC Authorization Form
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SSDS, Inc
DirtCheapPipes.com
6305 Wurzbach Rd Phone: 877-276-7310
San Antonio, TX 78240 Fax: 210-767-1570
Credit Card Authorization
SSDS, INC REQUIRES THAT ALL CUSTOMERS PAYING WITH A CREDIT CARD SIGN AND DATE THE
CREDIT CARD AUTHORIZATION FORM GIVING SSDS, INC THE AUTHORIZATION TO CHARGE YOUR
CREDIT CARD FOR YOUR PURCHASED MERCHANDISE. NO ORDERS WILL BE CHARGED OR SHIPPED
WITHOUT A SIGNED AUTHORIZATION FORM ON FILE.
_______________________________ _________________________
NAME OF ACCOUNT WITH SSDS EMAIL ADDRESS
_______________________________ _________________________
NAME ON CREDIT CARD CREDIT CARD NUMBER
_________ ___________
CVS CODE EXP DATE
3 OR 4 DIGIT NUMBER ON BACK OF CARD AFTER ACCOUNT NUMBER
TYPE OF CARD _______MASTERCARD
_______VISA
_______DISCOVER
I FULLY UNDERSTAND AND AGREE TO THE TERMS STATED ABOVE AND ACKNOWLEDGE THAT SSDS,
INC WILL CHARGE MY PURCHASES ON THE REFERENCED CREDIT CARD.
I AM AUTHORIZED TO USE THIS CHARGE CARD FOR THIS BUSINESS.
_______________________________ _________________________
PRINTED NAME DATE
_______________________________
SIGNATURE
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