Complete this form on screen and click here to print. We can accept only a signed original in order to record your information.
PAYMENT BY CREDIT CARD AUTHORIZATION
Bay Disposal Account Information
Contact Information
Customer Name (as it appears on the bill):
Cardholder’s Name (as it appears on the card):
Bay Disposal Account Number(s):
Cardholder’s Address:
City /State/Zip
E-Mail:
Telephone:
I hereby authorize Bay Disposal, Inc. to charge automatically the following credit card account identified herein
for the service(s) listed below:
Please check the appropriate box.
Commercial Service
Residential Service
Other:
Required Credit Card Information:
Mastercard Number:
Expiration Date:
Three Digit Code #:
Discover Number:
Expiration Date:
Three Digit Code #:
01
01
Visa Number:
2008
Expiration Date:
01
American Express Number:
2008
Three Digit Code #:
2008
Expiration Date:
01
Four Digit Code #:
2008
I understand and approve all of the above as evidenced by my signature below and acknowledge having read
this authorization.
It is your responsibility to contact our office should you receive a new credit card number, or if your card expires so that
we can update our records to reflect your current information.
Authorizing Signature:
Date:
Please return this form to Bay Disposal, Inc.
465 E. Indian River Road, Norfolk, Virginia 23523 757-857-9700 Fax: 757-857-1099
www.BayDisposal.com