R&M Materials Handling, Inc

4501 Gateway Boulevard

Springfield, Ohio 45502

CREDIT CARD AUTHORIZATION CHARGE

(Autorizacion Cargo Tarjeta De Credito)
BUYER:
(Comprador)

___________________________________________________________

BILL TO ADDRESS:
(Direccion)

__________________________________________________________

CARDHOLDERS NAME: __________________________________________________________

(Titular De Tarjeta)
CREDIT CARD #:
(N Tarjeta De Credito)

__________________________________________________________

EXPIRATION DATE:
(Fecha De Expiracion)

___________

VISA ___
BENEFICIARY:
(Beneficiario)
REFERENCE:
(Referencia)

MASTERCARD ___

AMERICAN EXPRESS ___

DINERS CLUB ___

____________________________________________________________
_____________________________________________________________

AMOUNT TO BE CHARGED: ____________________________

(Importe A Cargar)
_______________________________________________________
Authorized Signature