6175 NW 167th Street – Unit G-13
Miami Lakes, FL 33015
Phone: 305-362-4320 Fax: 305-362-4502

CREDIT CARD AUTHORIZATION FORM

Billing Information
Company Name
Cardholder Name*
First Name Last Name
Select One Credit Card*
- AMEX
- VISA
- MASTERCARD
- DISCOVER
Credit Card Number*
Expiration Date*
*
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
Shipping Address*
Street Address Unit/Bay/Suite/Apt City State ZIP Code
Total Amount Plus Sales Tax*

If Tax Exempt; Include Current Year Tax Exempt Certificate
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, Shipping & Handling Charges.
Sign*
First Name Last Name
Agreement*
- By submitting this form you accept all charges pertaining to the information entered above.

Billing Information