2830 SIMPSON CIRCLE Norcross, GA 30071 770 809 1017 – 678 462 1023 / Fax 404 – 506 9305 Credit Card Payment Authorization Form Sign and complete this form to authorize BRS Roofing Supply. To make a debit to your credit card listed below. Permission By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single OR multiple transactions, and does not provide for any additional unrelated debits or credits to your account. Full Name Authorized Amount year 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 Month 01 02 03 04 05 06 07 08 09 10 11 12 Payment description Billing address 1 State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia Puerto Rico Guam American Samoa U.S. Virgin Islands Northern Mariana Islands City ZIP Code Email Phone number Account Type Visa Mastercard Amex Discover Cardholder name Account number Expiration date CVV Upload Credit card (front and Back) Date Upload ID Authorization I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form. Send