AUTHORIZATION TO BILL CREDIT CARD

 

If you are receiving this form it is that you have placed a PO with Canics, Inc and have agreed to pay by credit card.

 

Please print and fill in all of the sections below and fax back to 450-447-3547

****Your order will not be processed unless all sections are completed****

 

Reference Quote or Part ID:______________________________________________________________

 

Company Name:

 

Tel :

Fax :

 

Your PO reference:

 

Card holder’s name:

 

Type of credit card:

Visa

Mastercard

 

 

Credit card number:

 

 

Security code: ( 3-4 digits on back of card )

Expiry:

 

Authorized transaction amount:

Currency:

Note: a 3% surcharge will apply for all credit card orders.

 

Card holder’s signature:

 

Billing address of credit card:

Bank institution:

 

 

Bank Institution Phone number:

 

Canics, Inc.      1231 Ch. des Patriotes, Richelieu, Quebec, Canada J3L 4W7

·Tel:(450) 447-6700        ·Fax:(450) 447-3547       ·E-mail: sales@canics.com      ·URL: www.canics.com

*Canics est une marque de commerce de Canics, Inc., Canics is a trademark of Canics, Inc.