Credit Card Authorization (With AMEX)

Supreme Appliance VB, LLC

Servicing The Greater Hampton Roads License Number: 81-3540301

Phone Number: 757-479-8518

CREDIT CARD ON FILE AUTHORIZATION FORM

This form is for you to supply Supreme Appliance VB, LLC with credit card information to keep on file for the payment of all services and fees. A new form must be completed for each card kept on file. Once filled out please E-mail to

Supreme Appliance VB, LLC accepts the following credit cards.

Visa, MasterCard, Discover & American Express

Card Type Accepted: Visa / MasterCard / Discover / AmEx

Name on Card: Click or tap here to enter text. Card Number: Click or tap here to enter text. Expiration Date: Click or tap here to enter text. CVV Code (Security Code): Click or tap here to enter text. Card holder Signature: Click or tap here to enter text. Billing Address: Click or tap here to enter text. City: Click or tap here to enter text. State: Click or tap here to enter text. Zip Code: Click or tap here to enter text.

Please accompany this form with a copy of the "Appliance Management Form" for review. Once Approved, Diagnostic Fee will be charge to your Credit Card. Diagnostic Fee will be deducted from total invoice and Credit Card will be charge for the balance due upon completion. In some occasions a deposit for any Special Order Part maybe required and will as well be deducted from total invoice.

I hereby authorize Supreme Appliance VB, LLC to charge the credit card listed above for the payment of all services and fees required. This credit card will be kept on file and will remain in effect until the expiration of the credit card account. A new form must be submitted if any information such as credit card expirations or change of billing address occure. Applicants agrees to pay the cost for any returned or challenged payments.

Client Signature: Click or tap here to enter text.

Date: Click or tap here to enter text.