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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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.
