J & H Diesel Service, Inc.     J & H Turbo Service, Inc.

P.O. Box 5278   3401 Hwy 82 East       Greenville, MS  38704-5278  USA

Phone: 662-378-8711  FAX: 662-332-3561

 

Credit Card Authorization Form

 

 Date:__________________

 

 

Billing Name: ___________________________________________________

 

Contact: _______________________________________________________

 

Billing Address: _________________________________________________

 

Billing City, State, Zip: ____________________________________________

 

Phone #: ________________________   Fax #:_______________________

 

Email Address: _________________________________________________

 

 

Ship to Name: __________________________________________________

 

Shipping Address: _______________________________________________

 

Ship to City, State, Zip: ____________________________________________

 

 

Credit Card:  Master Card  /  Visa  /  American Express / Discover

Name on Credit Card: ____________________________________________
 

 

Card #: _________________________________ Exp Date: _____________
 

 

CCV#: _________ (Three digit Security code on back of card)
 

 

Total Amount: $____________________

 

I hereby authorize J & H Diesel / J & H Turbo to charge my credit
card for purchases as I have hereunder ordered.

 

 

__________________________________

Authorized Cardholder Signature

  

Internal use- Ref Invoice #:______________