CREDIT CARD AUTHORIZATION FORM

Caution: After you fill out this form, print, sign and submit it to the Brite-Lite office. If you're using a public computer, be sure to click "Clear" button when finished in order to prevent identity theft. It is also recommended that you close the browser when done.
Attention Accounts Receivables
CREDIT CARD TYPE:
VISA MASTERCARD Visa or MasterCard Only
CREDIT CARD NUMBER:
 EXP:
CARD IDENTIFICATION #:
  (3 digits located on the back of the credit card)
COMPANY NAME:
CARD HOLDER NAME:
BILLING ADDRESS:
CITY:
PROVINCE/STATE:
COUNTRY:
POSTAL CODE/ZIP:
PHONE:
FAX:
AMOUNT CHARGED:
 $     IP Address  
NOTE:
(please specify Sales Order # or any additional information)

I, ___________________________________________________, understand and hereby authorize Brite-Lite to charge my credit card for the above amount. I agree to the polices, terms and conditions for this transaction.

Please PRINT this form, sign and submit it to the Brite-Lite office.
When finished, please click "Clear" button below and close browser.
Sign: _____________________________________ Date: ______________



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