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Follow the steps to download and upload a credit card approval form
Date *
First Name *
Last Name *
GEORGIA ID Verification / Drivers License *
I agree * I confirm that the following information is accurate and you are willing participant in BRS Roofing Supply, LLC charging the following credit card, debit card. In addition you acknowledge that no discount will be offered when paying via credit or debit card.
Card Holder Name *
Phone *
Company Name *
Email * We recommend using a personal Email address to ensure the best experience on our website.
Street Address *
City *
State / Province / Region *
ZIP / Postal Code *
Country * —Please choose an option—AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands
Card Type * Card TypeVisaMaster CardAmexDiscovery
Credit Card Number *
Expiration Date *
Card Sec Code *
Amount to Charge *
Description of Merchandise or Invoice *
Upload Front ID *
Upload a bill with matching billing address as shown on ID *
Upload Credit Card Front *
Upload Credit Card Back *
Disclaimer for Use of Credit Card Form / Descargo de responsabilidad para el uso del formulario de tarjeta de crédito
Affidavit of Truthfulness / Declaración jurada de veracidad
Consent * I authorize BRS Roofing Supply, LLC to charge the agreed amount listed above to my credit card provided herein. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement.
Signature *
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By using this credit card form, you agree to the following terms and conditions: • Accuracy of Information: You confirm that all the information provided in this form is accurate and truthful to the best of your knowledge. • Legal Consequences of Fraud: Submitting fraudulent or misleading information may result in legal consequences, including but not limited to prosecution under federal law. In accordance with 18 U.S. Code § 1028, anyone who knowingly provides false information or attempts to commit fraud may face penalties including fines and imprisonment. • Liability Waiver: BRS Roofing Supply is not responsible for any misrepresentation, fraud, or theft committed by users of this form. Users are solely responsible for the accuracy and legitimacy of the information they submit. • Data Protection: By submitting this form, you consent to the use of the provided data for the purpose of completing your transaction. Your data will be handled in compliance with applicable privacy laws. • Use of Services: The use of this form is intended only for authorized users. Any unauthorized or fraudulent use will be subject to prosecution under applicable laws.
Al utilizar este formulario de tarjeta de crédito, acepta los siguientes términos y condiciones: • Exactitud de la Información: Usted confirma que toda la información proporcionada en este formulario es precisa y verdadera a su mejor conocimiento. • Consecuencias Legales del Fraude: La presentación de información fraudulenta o engañosa puede resultar en consecuencias legales, incluidas, entre otras, el enjuiciamiento bajo la ley federal. De acuerdo con el 18 U.S. Code § 1028, cualquier persona que proporcione información falsa a sabiendas o intente cometer fraude puede enfrentar sanciones, incluidas multas y prisión. • Renuncia de Responsabilidad: BRS Roofing Supply no se hace responsable de ninguna tergiversación, fraude o robo cometido por los usuarios de este formulario. Los usuarios son los únicos responsables de la precisión y legitimidad de la información que envían. • Protección de Datos: Al enviar este formulario, usted consiente el uso de los datos proporcionados para el propósito de completar su transacción. Sus datos serán manejados de acuerdo con las leyes de privacidad aplicables. • Uso de los Servicios: El uso de este formulario está destinado únicamente para usuarios autorizados. Cualquier uso no autorizado o fraudulento será objeto de enjuiciamiento conforme a las leyes aplicables.
By submitting this form, I hereby declare under penalty of perjury under the laws of the United States of America that the information provided is true, accurate, and not intended to defraud. I understand that submitting false or fraudulent information is a violation of 18 U.S. Code § 1028 (Fraud and related activity in connection with identification documents, authentication features, and information) and may result in severe penalties, including fines and imprisonment.
Al enviar este formulario, declaro bajo pena de perjurio conforme a las leyes de los Estados Unidos de América que la información proporcionada es verdadera, precisa y no está destinada a defraudar. Entiendo que proporcionar información falsa o fraudulenta es una violación del 18 U.S. Code § 1028 (Fraude y actividades relacionadas con documentos de identificación, características de autenticación e información), lo que puede resultar en sanciones severas, incluidas multas y prisión.
By signing or submitting this form, I authorize BRS Roofing Supply, LLC to charge my credit/debit card for US$____________, corresponding to Customer Order (CO) #: _____________.
I confirm that the goods/services requested by me or my company were delivered or picked up, serving as proof of fulfillment.
I waive the right to dispute these charges as “unauthorized” if they match the agreed CO and amount.
For in-person transactions, I presented valid government-issued ID. For online/remote transactions, I completed this form via the secure BRS Roofing Supply link, which records my IP, email, and timestamp as proof of consent.
I acknowledge that any chargeback claim stating lack of authorization will be treated as fraudulent misrepresentation, since this signed/e-submitted form (with CO#, amount, and personal data) is legal proof of authorization.
I understand that a credit/debit card processing fee of up to 1.9% may apply to this transaction (unless prohibited by law). This fee may be waived at the sole discretion of BRS Roofing Supply; however, if the processing fee is waived, no additional discounts will be applied to the invoice.
I authorize BRS Roofing Supply to securely retain this form, proof of delivery, and related documentation for submission as evidence in case of dispute.
