CREDIT CARD AUTHORIZATION FORM

CREDIT CARD AUTHORIZATION FORM
Please fill in the following information/ S’il vous plait complissez les informations.
CREDIT CARD INFORMATION/ L’information du carte de credit
American Express – Visa – MasterCard
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CREDIT CARD NUMBER & EXPIRATION DATE/ CARTE DE CREDIT DE DATE D’EXPIRATION
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3 DIGIT SCECURITY CODE ON BACK OF CARD (VISA ONLY)/3 NUMERO DE SECURITE A L’ARRIERE DE LA CARTE
(VISA SEULEMENT).
AMOUNT TO BE PROCESSED /MONTANT A TRAITE
INVOICE/ORDER # / NUMERO DE FACTURE /DE COMMANDE
ACCOUNT NAME/NUMBER/ NOM DE COMPTE /NUMERO
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PRINT NAME AS IT APPEARS ON CREDIT CARD/ ECRIRE VOTRE NOM TEL QU’IL APPARAIT SUR LA CARTE DE CREDIT
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COMPANY NAME/ NOM DE LA COMPAGNIE
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CITY /PROVINCE/ VILLE/PROVINCE
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CONTACT PHONE NUMBER/ NUMERO DE TELEPHONE A CONTACTER
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AUTHORIZED CARD HOLDER SIGNATURE/SIGNATURE AUTORISE DU TITULAIRE DE LA CARTE
I, the undersigned, authorize Wurth Canada, to charge the above referenced Credit card.
Würth Canada Limited/Limitée, 6330 Tomken Road, Mississauga, Ontario, L5T 1N2
Tel : / (800) 263 5002 Fax : (905) 564 4809
Email: [email protected]
www.wurthcanada.com