ALL DADE LAWNMOWERS
1495 NW. 111 Ave
Miami, Florida 33172
_________________________________________________________________________________________

CREDIT CARD PAYMENT AUTHORIZATION FORM

Account Number"_________________                        Invoice Number:_____________________

Company Name:_________________________________________________________________

Address:_______________________________________________________________________

City:_______________________  State:___________  Zip:__________  Country:____________

Phone:(______)___________________________  Fax:(______)__________________________
 

Please Circle One:                               

________________________________________________                  ____________________
Credit CARD NUMBER (Please list all numbers on card)                               Expiration Date

I, the above named cardholder, hereby authorize ALLDADE to bill my account for the sum of

$_____________ plus shipping charges for goods and/or services ordered on _______________

                           Part Number                                                  Quanity

I, the above named cardholder, also authorize ALLDADE to bill my account for any recurring

Amounts including but not limited to any shipping and handling charges per invoice incurred.

Cardholder's Name:______________________________________________________________
                                                   (Please Print Exactly as it appears on the card)

Cardholder's Signature:_______________________________________  Date:_______________

Return to All DADE's Home Page