Credit Card Payment Authorization Form

Sign and complete this form to authorize Burlington Materials/ Burlington Design Gallery to make a the debit transaction to your credit card listed below. 

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By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date.

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PLEASE COMPLETE THE INFORMATON BELOW:

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I,                                                                                               authorize Burlington Design Gallery/ Burlington Materials to

charge my credit card account indicated below for                                                on or after  

The payment is for                                                              .

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SIGNATURE:

DATE:

I authorize Burlington Building Materials, Inc. DBA Burlington Design Gallery to charge the credit card indicated in this authorization form. This payment authorization is for the goods/services described above, for the amount indicated above only, I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company: so long as the transaction corresponds to the terms indicated in this form. By signing this form I agree to the terms and conditions of the quotes, sales order or invoice mentioned above.

Thanks for submitting!