CC Authorization Form

DISTRIBUTORS OF POOL TILE AND MORE 1763 APEX ROAD SARASOTA, FL 34240 PHONE: (941) 378-9331 FAX: (941)379-5458
CREDIT CARD AUTHORIZATION
COMPANY NAME*
NAME ON CARD*
Address*

ADDRESS

Street Address Line 2

CITYState / Province

Postal / Zip Code
STATE*
ZIP CODE*
PHONE*
EMAIL*
example@example.com
CREDIT CARD TO BE KEPT ON FILE:
Card Kept On File*

YesNo
We do not collect Credit Card information online for security purposes. Please fill in the details of the card below other than the CC number and call the office at (941) 378-9331 to provide the Credit Card number over the phone. Your Security is TOP of MIND for us
BILLING ZIP CODE*
SIGNATURE

Clear
DATE*

MonthDayYear
Date
I AUTHORIZE LUV TILE ENTERPRISES TO KEEP THIS

ON FILE FOR PURCHASES BY MY COMPANY.
SIGNATURE*

Clear
DATE*

MonthDayYear
Date
Should be Empty: