Deflecto-Canada-Credit-Card-Authorization

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					           Deflecto Canada , 221 Bunting Road, St. Catharines, ON L2M 3Y2 Canada
    Phone: 905.641.8872 Ext 41     Fax: 905.641.2696     E-mail address: defcanar@deflecto.com


            CREDIT CARD PAYMENTS AUTHORIZATION FORM

 Please fill-up this form in order for us to process your payment for Deflecto Canada on the credit
  card indicated below. You need to fill-up this form only once as we will keep the information in
             your file and use this credit card for payments of your company's purchases.

 Attn.
Brian C.
COMPANY'S NAME:

CITY:                                      PHONE NUMBER:

METHOD OF PAYMENT:
                             VISA
                             MASTER CARD


CURRENCY:                    CAN DOLLARS
                             US DOLLARS

CREDIT CARD #:


EXPIRY DATE:

NAME ON THE CREDIT CARD (PRINT):

DATE:

SIGNATURE OF AUTHORIZED PERSON:

FAX NUMBER OR EMAIL FOR THE PAYMENT CONFIRMATION:


            Please fax back to Natasha at Deflecto Canada - 905.641.2696

				
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