CREDIT CARD AUTHORIZATION THIS SPACE IS FOR THE SHIP TO ADDRESS: Customer Name: Contact:
Phone:
Fax:
State:
Zip:
Street Address: City:
In order to expedite processing and scheduling of your order, you have authorized full payment to be charged to the credit card shown below. All payments made are in accordance with the specified terms below.
CHARGE IT TO MY:
Visa
Master Card
Discover
THIS SPACE IS WHERE THE CREDIT CARD IS BILLED TO:
Card Number: Expiration Date:
Month
Year
Name on Card Address card is billed to, Street address:
City
State:
Zip:
Amount charged $ Security Code
(last 3 digits on the back of card in signature area)
***Cardholder Signature **Please provide a copy of your driver’s license for security purposes. Important Note: Please mail or fax to (985) 542-6560 as soon as possible, we cannot begin until the above is received. ALACK – North Shore 17420 Highway 190 Hammond, LA 70401 (985) 345-9476
SRE – Sarasota 5330 Pinkney Ave. Bldg. C Sarasota, FL 34233 (941) 924-1410
SRE – Fort Myers 1962 Honda Dr. Fort Myers, FL 33907 (239) 226-4555
LOTZ – New Orleans 5133 River Rd. Harahan, LA 70123 (504) 733-3790