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WESTERN HYDROSTATICS, INC. 1956 KEATS DR. RIVERSIDE, CA. 92501-1747 (951) 784-2133 Fax (951) 784-8423 http://www.weshyd.com / [email protected] CREDIT CARD AUTHORIZATION FORM All information will remain confidential To Your Reference Company Our Reference Subject Order Confirmation Date I, __________________________________ Hereby certify that as _____________________________________ (Print Name) (Title) of_________________________________________________________________________________________ _________________________________________________________________________________________ (Name and address of Organization) Have authorization to purchase goods and / or services on Visa, MasterCard, Discover or American Express. Amount to be charged: $__________________________ (USD) Cardmember authorizes Western Hydrostatics, Inc. to charge the account listed below and agrees to perform the obligations set forth in the Cardmember’s agreement with the issuer. Card holder – sign and date below: Signature: ___________________________________________ Date: ___________________________________________ Blanket Purchase: (For this and future orders) Card Number: VISA MASTERCARD DISCOVER AMERICAN EXPRESS (Circle One) Card Member name: _____________________________________________________________ (Exactly as on Card) Card Statement Billing Address: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Phone Number: _______________________________ Expiration Date: _______________ Card Identification Number: _______________ (Last 3 digits on back of card) (4 digits on front of American Express)
