Credit Card Authorization Form

Card Type:*

AMEX

Discover

Master Card

US Goverment P-Card

VISA

Other

Card Holder Name (as shown on card):*

First

Last

Cardholder Phone*

Cardholder Email*

Card Number: *

Expiration Date (mm/yyyy):*

CVV Number*

I, authorize Collsam Distribution, Inc.to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

Please attach a copy of the front and back of the card

Please attach a copy of A Goverment Issued ID*

Cardholder NSignature*

Date*

I consent collecting this data and processing it according to Privacy and Cookie Policy of this website.

Credit Card Authorization Form

Credit Card Authorization Form

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