Sammarco Stone & Supply, Inc.
Masonry & Building Supplies
173 Oak Street
New Rochelle, New York 10801
(914) 636-6563 Fax (914) 636-6597
CREDIT CARD LETTER AUTHORIZATION
Attention To: _________________
Invoice/Estimate Number: _______________
I _______________________________ hereby authorize Sammarco Stone & Supply, Inc.
to charge the sum of $_______________ or keep a credit card authorization on file for future
charges. If credit card authorization is kept on file, it is up to the card holder to keep track of the
American Express MasterCard Visa.
Please check yes or no to keep authorization on file.
YES, Keep on file NO, Do not keep on file
Credit Card Number: ______________________________________________
Exp. Date: ______/_______/______ CSV Code: ______________
I agree to pay the above charges and that I will not deny any portion of the charges for any reason.
Card Holder’s Name: ________________________________________________________
Credit Card Billing Address: ___________________________________________________
City, State & Zip: ____________________________________________________________
Phone Number: ____________________________________________________________
Card Holder’s Signature
This form must be accompanied by a photocopy of both sides of your Credit Card and a photocopy of
the Cardholder’s Driver License.
Please fax this form and photocopies to (914) 636-6597.