Credit Card Authorization Form

All Fields Are Required to Complete This Form

Card Number:

Card Expiration:

Card CVV:

Cardholder Name:

Cardholder Billing Address:

City:

State:

Zip Code:

Phone Number:

Email Address:

Authorized Names or Password:

Address of Service or Delivery

Is the billing address the same for service or delivery?

Address:

City:

State:

Zip Code:

With my signature below, I hereby authorize to maintain a record of my Debit Card or Credit Card information for card ending with the last 4 digits of expiration date of . This authorization is for Oil Deliveries, Service calls, Installation provided by .

I authorize to charge my Debit Card or Credit Card at my request. This account WILL NOT be set up on auto pay. will secure this Debit Card or Credit Card information on a secure encrypted server provided by the processor of 's choosing.

I authorize to charge my Debit Card or Credit Card on AUTO-PAY. This account WILL BE set up on AUTO-PAY. ALL deliveries will be charged to this card including any delivery for non-budget accounts. An auto payment will also be authorized on this card up to $500.00. Any service call on non-budget programs will be charged to this card. You will be notified by mail/email of your monthly payment with payment date to the card on file.

Signature of Cardholder:

DO NOT CLICK MORE THAN 1 TIME!