Credit Card Authorization - Sourdough Fuel Co.-Sourdough Fuel

Credit Card Authorization - Sourdough Fuel Co.

Sourdough Fuel Auto Pay Authorization

First Name

Last Name

Phone Number

Delivery Address

Select ONE: I wish to have:

All charges paid with my auto pay selection

Only Budget Program payments paid.

Budget payments & Furnace Invoices paid.

I understand my payment will automatically be transferred from my credit card or bank account to Sourdough Fuel. I authorize my credit card or bank to make payments to Sourdough Fuel. I understand and agree to the terms listed above.

Signature

Date

Sourdough Fuel will keep all information entered on this form strictly confidential.

Option 1: Credit Card

Credit Card

Visa

MasterCard

Discover

My Card #

Expiration Date:

Option 2: Debit Card

Debit Card

Visa Check Card

MasterCard Debit Card

My Card #

Expiration Date:

For Office Use Only

Customer Code:

Date Entered:

Inputted By:

Last Four: