N & H Electronics
1100 Hardy St
Hattiesburg, MS 39401
800-264-8808 | 601-450-1491
FAX 601-450-1491
________________________________________________________________

Credit Card Authorization Form

NAME OF AUTHORIZED CARD HOLDER _________________________________

BUSINESS NAME __________________________________________________

CARDHOLDER BILLING ADDRESS _____________________________________

________________________________________________________________

PHYSICAL ADDRESS _______________________________________________

________________________________________________________________

TELEPHONE # ____________________________________________________

TYPE OF CARD ___________________________________________________

CARD ACCOUNT # _________________________________________________

EXPIRATION DATE ________________________________________________

AUTHORIZED SIGNATURE ___________________________________________

DATE ___________________________________________________________

PLEASE SEND A COPY OF THE CREDIT CARD ALONG WITH A COPY OF YOUR
DRIVERS LICENSE.