Credit Card Authorization Form

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Payment Type *

• Visa
• MasterCard
• Discover

Name of Cardholder *

Contact Email Address *

Company Name *

Billing Address *

City *

State *

ZIP *

purchase. agreed (last

Phone Number *

Last 4 of Credit Card Number *

Expiration Date *

CVV (last 3 of the back) *

Amount to Pay $ *

I, __ (type name on card)__ authorize SIMS PLASTICS to charge my credit card above for this agreed upon purchase. *

Submit

After pressing the submit button, please send a copy of your Driver’s License and any questions to: [email protected]