PharmChem, Inc.

2411 E. Loop 820 N.

Fort Worth, TX  76118

 

Fax Contact:            Matthew Hartley (817-590-2537)                  Date:______________________

                               Doug Crook (817-590-0571)

 

 

Fax Number:            (817) 590-4304

 

 

AUTHORIZATION FOR CREDIT CARD PAYMENT

 

 

This document is provided for authorization to debit the indicated charge account for services/products provided.

 

 

Name of Authorized Card Holder:                                                                                            

 

Phone Number:                                                                                                                               

 

            Type of Account (circle one):

 

            American Express                         VISA*             MASTERCARD*

 

Credit Card Account Number:                                                                     Expires:                   

 

* Three-Digit Security Code:                                                                        

 

Company Name:                                                                                                                                   

 

Billing Address:                                                                                                                               

 

                                                                                                                                                                       

 

Customer Number (Billing Account Number):                                                                 

 

Transaction Description (Invoice Number):                                                                             

 

Authorized Amount:                                                                                                                   

 

 

Signature of Authorized Card Holder: