6157 NW 167th Street – Unit F-9Miami Lakes, FL 33015Phone: 305-362-4320 Fax: 305-362-4502 CREDIT CARD AUTHORIZATION FORM Billing InformationCompany NameContact Name* First Name Last Name Contact Phone*Email* Select One Credit Card*AMEXVISAMASTERCARDDISCOVERCardholder Name* First Name Last Name Credit Card Number*Expiration Date*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*2020202120222023202420252026202720282029Card Security Code*Billing Address* Street Address Unit/Bay/Suite/Apt City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Shipping To Check Box If Shipping Address Is The Same As Billing Address Company NameContact Name* First Name Last Name Contact Phone*Shipping Address* Street Address Unit/Bay/Suite/Apt City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Tag OrderYour Purchase Order NumberTotal Amount Without Tax* Applicable Sales Tax Will Be Added To This Amount. If Tax Exempt; Provide Current Year Tax Exempt Certificate. A 3% Merchant Fee Will Be Added To The Total Amount Including The Sales Tax As Mentioned In The E-QUOTATION Under “Conditions & Comments”ImportantCardholder agrees that all items being purchased are non-cancellable/non-returnable and agrees to PV&A’s Quotation/Conditions and Submittals (if applicable). Cardholder also acknowledges that all orders may be immediately terminated at PV&A’s discretion if any charges are declined. By entering my name in the fields below, I hereby authorize PV&A to charge the above Credit Card account in the amount specified above, including applicable Taxes. The price is full freight allowed to South Florida.Sign* First Name Last Name Agreement* By submitting this form you accept all charges pertaining to the information entered above.