Credit Card Processing Form (PDF)

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					    Credit Card Processing Form

    COMPANY INFORMATION

    Business Name .................................................................................................................................................................................

    DBA or AKA Name ...........................................................................................................................................................................

    Name as it Appears on Credit Card ....................................................................................................................................................

    Street Address ...................................................................................................................................................................................

    City ..................................... Country ................ State/Province ......Zip Postal Code.............................................................................

    Area Code and Phone Number........................................................Area Code and Fax Number ..........................................................

    Amount:$ .........................................................................................................................................................................................

    Credit Card Number ......................................................................Expiration ....................................................................................

    Verification Code (last three digits on back of card) ...............................................................................................................................

    Name as it Appears on Credit Card ....................................................................................................................................................

    Cardholder agrees to be bound by the terms of Lighting Science Group’s payment and refund policies as stated on invoices. Cardhold-
    er agrees to be responsible for payment of fees if cancellations are made after the cancellation deadline. If payment is for someone
    other than the credit card holder, please identify to whom this payment is to be applied. I agree to this authorization of charge to this
    credit card.


    Print Name .............................................................................. Signature ................................................................................

    Invoice/Sales Order Payment to be Applied to ...........................................................................................................................

    ............................................................................................................................................................................................




                                                          1227 South Patrick Drive, Satellite Beach, FL 32937                  www.lsgc.com            Phone: 321.779.5520             Fax:321.779.5521

LSG_104

				
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