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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. 

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:

I,                                                                                               authorize Burlington Design Gallery/ Burlington Materials to

 

 

charge my credit card account indicated below for                                                on or after  

 

 

The payment is for                                                              .

 

 

 

 

Credit Card Information

Account Type
Card Type

(CVV Code/ Security Code: 3-digit number on back of Visa/Master Bard/ Discover.    Amex:  4-digit printed on front.)

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!

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