Welch Equipment COD Customer Request Form

Welch Equipment COD Customer Request Form
By completing the below, I (the customer) acknowledge that this account is being set up as a Collect on Delivery (COD) account and a binding agreement that payment is due at time of service.
Business/Customer Name
Address 1
Address 2
City
State
Zip code
Tax Jurisdictions
(if exempt, please provide copy of exemption)
Phone Number
Fax Number
Email address
example@example.com
Payment Method

Visa Mastercard American Express Discover
Name as it appears on Card
Credit Card Number
Expiration Date

Month Day Year
Date
Security Code
Billing Zip Code
Customer/ Contact Name
Customer Signature

Clear
Driver License #
Driver License Exp Date

Month Day Year
Date
This box to be completed By Welch Equipment
Welch Employee
Customer #
Should be Empty: