6157 NW 167th Street – Unit F-9Miami Lakes, FL 33015Phone: 305-362-4320 Fax: 305-362-4502 CREDIT CARD AUTHORIZATION FORM "*" indicates required fields Billing InformationCompany 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*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear*20222023202420252026202720282029Card Security Code* Billing Address* Street Address Unit/Bay/Suite/Apt City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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”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.