6157 NW 167th Street – Unit F-9
Miami Lakes, FL 33015
Phone: 305-362-4320 Fax: 305-362-4502

CREDIT CARD AUTHORIZATION FORM

"*" indicates required fields

Billing Information

Company Name

Contact Name*

First Name Last Name

Contact Phone*

Email*

Select One Credit Card*

AMEX

VISA

MASTERCARD

DISCOVER

Cardholder Name*

First Name Last Name

Credit Card Number*

Expiration Date*

Year*

Card Security Code*

Billing Address*

Street Address Unit/Bay/Suite/Apt City State ZIP Code

Shipping To

Check Box If Shipping Address Is The Same As Billing Address

Company Name

Contact Name*

First Name Last Name

Contact Phone*

Shipping Address*

Street Address Unit/Bay/Suite/Apt City State ZIP Code

Tag Order

Your Purchase Order Number

Total 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”

Important

Cardholder 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.