Authorization Form | Cool Air USA

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CREDIT CARD AUTHORIZATION

All * Marked Fields Are Mendatory Fields.

Job Number *:

Cardholder Name *:

Billing Address *:

Card Type *:

Credit Card Number *:

Expiration Date *:

Identification Number*:

(3-4 digits located on the back of card your card)

Amount to be charged to account *: $

Being the cardholder, by signing below FI understand and agree to the

terms set forth in this agreement, agree to pay, for the Services provided by Cool Air USA. I further agree that in the event my credit card becomes invalid, I will provide For Cool Air USA, Inc with a new valid credit card upon request, to be charged for the payment of any outstanding balances owed to Cool Air USA, Inc.

I agree the Terms & Conditions.

Printed Name:

Document *:

Select Title :

Date:

(*for your security your ip address will be recorded)

02/23/2012