Thank you for agreeing to pay your bill by credit/debit card.
Your completion of this authorization form helps us to protect you, our valued customer, from credit card fraud. All information entered on this form will be kept strictly confidential by George Propane, Inc.
PREFER TO FILL THIS CREDIT/DEBIT CARD AUTHORIZATION OUT BY HAND? CLICK HERE FOR A PDF TO PRINT/SEND VIA FAX OR MAIL
1. Please fill out this credit/debit card automatic charge authorization in full. NOTE: *Required Field. 2. Read the Authorize Transactions & Conditions then click the agree check box. This will then turn on the SUBMIT button. 3. Click the SUBMIT button on the bottom to submit the final form. NOTE: You will be sent to a Thank You page when your application is successfully submitted.
Residential Commercial
*Company Name:
*first name:
*last name:
*email:
*address 1:
address 2:
*city :
*state: APO (AA) Alberta APO (AE) ALASKA ALABAMA APO (AP) ARKANSAS American Samoa ARIZONA British Columbia CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLUMBIA DELAWARE FLORIDA Micronesia FPO (FP) GEORGIA Guam HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANNA MASSACHUSETTS Manitoba MARYLAND MAINE Marshall Islands MICHIGAN MINNESOTA MISSOURI Northern Mariana Islands MISSISSIPPI MONTANA New Brunswick NORTH CAROLINA NORTH DAKOTA NEBRASKA NewFoundland NEW HAMPSHIRE NEW JERSEY NEW MEXICO Nova Scotia Northwest Territories Nunivat NEVADA NEW YORK OHIO OKLAHOMA Ontario OREGON PENNSYLVANIA Prince Edward Island Quebec Puerto Rico Palau RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA Saskatchewan TENNESSEE TEXAS UTAH VIRGINIA Virgin Islands VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING Yukon
*zip:
country:
billing name & address same as applicant?:
*address1:
address2:
*city:
Country:
*phone:
card type: Credit Debit
card company: Visa Mastercard Discover
*CC/DC number:
*expiration date: mm 01 02 03 04 05 06 07 08 09 10 11 12 yyyy 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008
*Authorized Charges: All Charges Budget Plan Propane Deliveries Only Service Invoices Only
TERMS & CONDITIONS: I hereby declare that the credit or debit card information above is true, accurate and appears in the name as stated.
I hereby authorize George Propane, Inc. to initiate entries to my account in the manner indicated and charge my credit or debit card account following each delivery of propane and/or upon receipt of an invoice for service. I am aware that I will receive a copy of the charge slip or paid invoice, which will act as my record of this transaction.
Further, I authorize my credit or debit card company to accept and to charge my account purchases. I understand that my propane delivery and/or service invoice amounts will be transferred from my credit or debit card until George Propane, Inc. receives further instructions from me.
I Agree with the above terms:
