PGC Installation Credit Card Authorization Form

Date of Charge

First Name *

Last Name *

Email *

Phone *

Description of Job

Credit Card Information

Amount To Charge

Credit Card Number *

Expiration Date *

CVC Number *

Billing Information

Full Name *

Address *

City *

State *

Postal code *

By signing below, I authorize Gerald Marseille and PGC Installation to charge my credit card provided herein for agreed amount listed above. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement. I understand that the charge will be used to purchase materials for the project and afterwards is nonrefundable and non-disputable.

Customer Signature *

Clear

By checking this box I agree to pay the full amount invoiced to me and I cannot dispute the charge.