Credit Card Authorization

If you are a new customers, please complete the following authorization to help finalize the set-up of your new account.

INSTRUCTIONS: To navigate from one blank to the next, please press the "Tab" button on your keyboard or use your mouse or tap to select the appropriate box. When finished completing the form, click the "Submit" button or press the "Enter" button on your keyboard to submit your request. Thank you!

Card Holder Information

Your Name (First Last):
Customer Account Number:
Card Holder Address:
City, State, Zip:
Phone Number:
Email Address:
Name on Card:

Payment Authorization


Card Type:
Card Number:
Exp. Date:
(mm/yyyy)
Card Identification Number:
(last 3 digits on back of card)

Agreement


Yes, I wish to authorize the purchase of services from Long Valley Dairy, Inc. using this credit card authorization form. The amount authorized to be charged shall reflect the total reflected on the invoice provided to me by Long Valley Dairy, Inc. I agree that I will pay for this service and indemnify and hold Long Valley Dairy, Inc. harmless against any liability pursuant to this authorization. I understand that my submission of this form will serve as the authorized signature on the credit card charge slip. This authorization is valid for a period of one (1) year. By submitting this Credit Card Authorization Form, I declare that I have fully read, understand and agree to abide by the Terms and Conditions of Long Valley Dairy, Inc. as stated.

Initials:

NOTE: All payments will be charged on the first (1st) and the sixteenth (16th) of each month, beginning from the date of this application.



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