Credit Card Authorization Form

Credit Card Authorization Form
Date*

MonthDayYear
Quick Fuel Account Number
A. Company Information
Legal Company Name*
Trade Name (if different from above)
Type of Business *
Years in Business *
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Company Website
Contact Name (Accounts Payable)*

First NameLast Name
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
E-mail (for Accounts Payable contact)*
B. Credit Card Information
Credit Card Number*
Expiration Date (MM/YY)*
Verification Number*
Credit Card Type*
Account Type*
Name that Appears on the Credit Card*

First NameLast Name
Use this Credit Card for Future Deliveries*

YesNo
C. Payment Terms & Conditions

By signing and delivering to QUICK FUEL this Credit Card Authorization Form, the undersigned signatory hereby represents and warrants to QUICK FUEL that the undersigned signatory: (i) is a duly elected, appointed and acting officer, manager, or representative of COMPANY, (ii) has the power to authorize QUICK FUEL to initiate debit entries to COMPANY’s credit card set forth in Section B, above, and such authorization shall remain in full force and effect until QUICK FUEL has received written notification from COMPANY that such authorization has been terminated; provided that QUICK FUEL shall have reasonable time and manner to effect such termination, (iii) has read and understands the Terms and Conditions of Sale of QUICK FUEL (which appear on the Terms & Conditions page of the Quick Fuel website www.quickfuel.com), (iv) has the power to bind COMPANY to the Terms and Conditions of Sale of QUICK FUEL.
Signature*

Clear
Print Name*

First NameLast Name
Date*

MonthDayYear
Title*
Should be Empty:

Credit Card Authorization Form

A. Company Information

B. Credit Card Information

C. Payment Terms & Conditions