Frozen Semen Credit Card Authorization

Frozen Semen Credit Card Authorization
I, the undersigned, do authorize Olney-Sandy Spring Veterinary Hospital to charge my credit card for the shipment and processing of frozen semen. I also authorize Olney-Sandy Spring Veterinary Hospital to charge my credit card number for the Federal Express fees to ship the dry shipper tank to its destination and back to Olney-Sandy Spring Veterinary Hospital (Visa, MasterCard and Discover only)

I agree to pay $20.00 for every day the dry shipper tank is not returned after the 5th business day. In addition, if the dry shipper tank is not returned within 30 days or if it is returned damaged, I understand that my credit card will be charged a $1,000.00 replacement fee.

By signing below I understand and agree to all of the conditions stated above.
Today’s Date*

MonthDayYear
Semen Information
Owner's Name

First NameLast Name
Dog’s Call Name
Payment Information
Name on Card
Credit Card Number
Expiration Date
Security code
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number
Email address
example@example.com
Signature of card holder

Clear
Please fax or email this form to us once completed.

*** Both forms (Frozen Semen Release/Transfer and Frozen Semen Credit Card Authorization) must be completed in full before the semen can be shipped. Advanced notice of 3-5 full business days (Mon.–Fri.) is required to prepare the shipment.

*This information will not be shared and will be destroyed after the dry shipper has been returned to OSSVH.
Should be Empty:

Frozen Semen Credit Card Authorization

Semen Information

Payment Information