CREDIT CARD AUTHORIZATION FORM

For County Disposal 

PLEASE PRINT OUT AND COMPLETE THIS AUTHORIZATION AND RETURN IT TO
OUR OFFICE BY FAX: (931) 657-8884 OR BY REGULAR MAILOR EMAIL.

Account Number _________________

Cardholder Name:_______________ Signature:__________________

Address: associated with Card:_______________________________

_______________________________________________________

Credit Card Type:VISA____ MASTERCARD____ DEBIT CARD____   

Credit Card Number:  ________ - ________ - ________ - ________ 
Expiration Date:________ / ________ 

Billing Zip Code: ________ Date to pull__________ 

Card Identification Number (last 3 digits located on the back of the credit card): ________ 

Amount Charged: $ ________________ (USD)

FAX or send the authorization to:   

     County Disposal

           Account Payable  
           9982 McMinnville Hwy 
            Quebeck Tn. 38579. 
            Phone (931) 520-8881   Fax (931) 657-8884

 customerservice@county-disposal.com

Note: to save on  your ink you can highlight the text for the form only and right click and print selection.