CTI Credit Card Charge Authorization Form

Credit Card Charge Authorization

Customer Information

Business Name:
Contact Name:
Street Address:
Suite Number:

City, State Zip:
Phone:
Fax:
E-mail:

Credit Card Information

Card #1

Name on Card:	*
Billing Street Address:	*
Billing City, State Zip:	*
Last 4 of Credit Card:	**
Credit Card Type:
Expiration Date:	/

*required

Card #2

Name on Card:
Billing Street Address:
Billing City, State Zip:
Last 4 of Credit Card:	**
Credit Card Type:
Expiration Date:	/

** Your account manager will contact you to collect the final card information for this authorization

Please read the terms below to Submit

It is all credit card companies policy that ALL PURCHASES PAID VIA CREDIT CARD MUST BE SHIPPED TO BILLING ADDRESS ON CREDIT CARD STATEMENT.

To help prevent fraud or use of a stolen card, Convergence Technologies and its group of companies will only ship product to the billing address on file with the credit card company for the credit card identified herein.

By entering your initials here: and checking the approval box below you are authorizing Convergence Technologies, Inc to charge your credit card for products and services sold to you by Convergence Technologies, Inc. and its group of companies. Only the card holder can type in the initials and check the box below.

Yes, I certify that I am the cardholder for the above listed card(s). I have read, understand and accept Convergence Technologies, Inc. standard terms and conditions of sale and authorize them to charge the above card for purchases made by the customer listed above.