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AUTOMATIC BILLING AUTHORIZATION FORM

PTSI’s Client Name: Harris and K, Inc. d/b/a Binger Springs

FROM CREDIT CARD: I authorize Premier Trade Solutions, Inc. to charge my bill on behalf of Binger Springs directly to the credit card(s) listed below: Primary Card Account

Contact & Payment Information

_________________________________

_________________________________

Name on Credit Card (exactly as printed on card)

Company Name

_________________________________

_________________________________

Address for Credit Card (Number & Street, Suite #)

Contact Name

Phone Number

_________________________________

_________________________________

Address for Credit Card (City, State Zip)

Fax Number or Email Address (For Receipts)

_________________________________

_________________________________

Credit Card Number

Invoice Number

Invoice Amount

______________ _________________

_________________________________

Card Expiration Date

3 Digit Security Code

Signature

(MM/YY)

(located on back of card)

Today’s Date

Bill all charges to the above card.

Premier Trade Solutions, Inc will fax or email a receipt to the above fax number or email address within 48 hours of processing the charge.

*Will also accept Discover

Binger Springs CC Form  

Binger springs cc form

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