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 Date Payment description Billing address 1 State SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern 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