DWI Credit Card Authorization

Discount Wholesalers, Inc. Credit Card Authorization Form

Company:

Customer name*

First NameLast Name

Phone Number*

Area CodePhone Number

E-mail*

Confirmation EmailEmail must match to current email on file

Billing Information: (as it appears on your credit card statement)

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Amount to be processed in USD*

Amount of Sales Order

Name as it appears on card*

First NameLast Name

Copy of a Photo ID is required*

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Copy of CC is required (You can block all of the numbers except the last 4 digits)*

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In using my Credit/Debit Card, I am agreeing to the following terms and conditions:

1. I understand that the merchandise I have purchased is Sold “As Is” with no guarantees or promises as to the conditions, qualities or values. Quantity and wholesale values have been audited and verified to my satisfaction by proof of executing this transaction. I will not hold Discount Wholesalers, Inc. responsible forany shortages in quantity, value, or quality once the goods have been released and transported out of their facility.

2. I agree to use this Credit/Debit Card with the same caution as with CASH. I agree to resolve any and all disputes directly with Discount Wholesalers, Inc. with no guarantees of mutual resolutions.

3. In execution of this purchase transaction, I agree to waive all rights according to card holders’ agreements with my issuing bank and agree to waive all rights to file disputes with my credit card company and waive any claims resulting in a charge back of funds from my issuing credit card company and Discount Wholesalers, Inc.

4. There will be a 3% Handling fee added to all orders where a Visa, MasterCard, or Discover Card is used. There
will be a 4% Handling fee added to all orders where American Express is used.

ALL CANCELLED ORDERS ARE SUBJECT TO A 20% (OF INVOICED AMOUNT) CANCELLATION FEE.

All information sent is strictly confidential and Discount Wholesalers Inc. adheres to the highest standards of account data protection.

Please Check the Appropriate Box(es):*

One Time Use: I hereby authorize Discount Wholesalers Inc. to charge the indicated credit card the amount indicated above. This is a one-time charge authorization. I am not authorizing Discount Wholesalers Inc. to setup my account within a recurring billing system. I understand that if I want Discount Wholesalers Inc. to charge any balances to my credit card in the future, I will need to submit another authorization form at that time.

Signature*

Date*

Date