CREDIT CARD AUTHORIZATION FORM
Customer Name:
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Service Address:
City:
Ph one:
State:
Zip:
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E-Mail:
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Cardholder Name:
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Card Number:
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Expiration Date:
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Billing Address:
I ( we),
(mm/yy)
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Card Type: Visa
C V Authorization Code ( 3 digits on back of card) :
City:
State:
MC
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Zip:
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hereb y authorize Weisz Selectio n Lawn & Land scap e Ser vices, I nc. to
per for m lawn maintenance and specially r eq uested ser vices/installatio ns at the address ind icated above witho ut
obtaining a signature at the time o f co mpletio n. I under stand all sales are final with no r efund s or exchanges. I
agr ee that I will pay fo r this p ur chase and ind emnif y and ho ld Weisz Selectio n Lawn & Land scape Ser vices, Inc.
har mless, against any liability p ur suant to this authorizatio n. I under stand that my signature o n this for m will
ser ve as my author ized signature o n the cred it card char ge slip . T he amo unt for regular ly sched uled lawn
ser vices will be deb ited for the follo wing mo nth's ser vices o n the 15th o f the mo nth, or the next b usiness day if
the 15th falls o n a weekend or ho lid ay. T he a mount for sp ecially req uested ser vices/installatio ns will be deb ited
within t wo (2) business days of the ser vice. Unless other wise instr ucted, the debit amo unt shall be eq ual to the
current balance due. If card is declined at time of processing, a late fee shall apply. To avoid late fee, please
contact o ur office if card information provided herein is no longer valid. This agreement may be cancelled if
funds are not available more than once in a twelve month p eriod. This authority is to remain in full force and
effect until Weisz Selectio n La wn & Landscape Ser vices, I nc. has received wr itten no tificatio n fro m me o f its
termination.
Authorized Signature:
Date:
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THE ABOVE INFORMATION IS CONFIDENTIAL AND WILL BE KEPT BY
WEISZ SELECTION LAWN & LANDSCAPE SERVICES, INC.
ACCOUNTS RECEIVABLE DEPARTMENT ONLY.
Weisz Selection Lawn & Landscape Services, Inc.
P.O. Box 176 Weston, Texas 75097 ~ Phone 972.838.4205 ~ Fax 972.838.4208
w w w . w e i s z s e l e c t i o n . c o m ~ [email protected]
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