Page 133 - KNA Supply Commodities Catalog 2024

KNA CREDIT CARD AUTHORIZATION

AUTHORIZATION TO CHARGE CREDIT CARD

COMPLETE AND SIGN THIS PORTION TO AUTHORIZE KNA SUPPLY TO CHARGE YOUR CREDIT CARD.

I _____________________________________ hereby authorize KNA Supply to charge the following credit card:
(Print Your Full Name)

Account Type: AMERICAN EXPRESS VISA MASTERCARD DISCOVER

Account Number: ______________________________________________________________________________

Expiration Date: ________________________ Validation Code (CVV2): _________________
(4 DIGITS ON AMEX)
Cardholder Name: _____________________________________________________________________________

Billing Address: ________________________________________________________________________________

City: _________________________________State: ________________________Zip Code: __________________

Business Name: _______________________________________________________________________________

Business Address: _____________________________________________________________________________

City: _________________________________State: ________________________Zip Code: __________________

For The Amount Of: (U. S.) $ _________________________ Payment of Invoice #: _________________________

SIGNATURE: ________________________________________________________ DATE: ____________________

PRINT NAME: _______________________________________________________ TITLE: _____________________

AUTHORIZATION TO KEEP CREDIT CARD ON FILE

COMPLETE AND SIGN THIS PORTION TO AUTHORIZE KNA SUPPLY TO KEEP YOUR CREDIT CARD ON FILE FOR FUTURE PAYMENTS.

I _____________________________________ hereby authorize KNA Supply to keep the above credit card on file:
(Print Your Full Name)

SIGNATURE: ________________________________________________________ DATE: ____________________
PRINT NAME: _______________________________________________________ TITLE: _____________________

PLEASE FAX THIS AUTHORIZATION WITH A VALID FORM OF PICTURE ID.

KNA Supply

PO Box 771826, Ocala, FL 34477 • TEL: (352) 351-1170 • FAX: (352) 351-2600 • www.knasupply.com