Credit Card Authorization Form

Cardholder Information

Name(Required)

AFD Account #(Required)

Billing Address(Required)

Street Address City State ZIP Code

Email(Required)

Phone(Required)

Credit Card Information

Card Type(Required)

Cardholder Name (as shown on card)(Required)

Card Number(Required)

Expiration Date (mm/yy)(Required)

Security Code (3 or 4 digit code CSC/CVV)(Required)

Cardholder ZIP Code (Billing Address)(Required)

Single Use Payment Info

Amount $(Required)

Invoice(s)(Required)

Keep This Credit Card on File for all Current and Future Invoice Payments(Required)

Yes

No

*By checking the "yes" box, you are agreeing to allow AF Distributors to use the credit card information above to be applied toward all invoices.

Consent

I authorize Arizona Fasteners dba AF Distributors to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account. I certify that I am an authorized user of this credit card and agree to the payment terms as long as the transactions correspond to the terms indicated in this authorization form.

Customer Initials(Required)

Date(Required)

Credit Card Authorization Form

Cardholder Information

Credit Card Information

Single Use Payment Info

Consent

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