Credit Card Form

I,____________________With______________________authorize Concrete Product Company (cpc) to charge my
Credit Card ,as indicated below,for any and all orders placed and shipped to my company at the address
shown below-or requested on individual orders.

Please Check One Box(Required

This authorization is valid for this order only, Order/Invoice#:----------------------------------

This is an open Authorization to allow charges to my Credit Card for all orders placed with Concrete Product
Company. Amount will very transaction, based on the order amounts.
I have read and to all of the terms and conditions on this page,as well as the terms and conditions of Concrete
Product Company or any other document that accompanies with this agreement.

I certify that I am the authorizer account holder for this Credit Card. I understand this is a legal binding
agreement between Concrete Product Company and______________________ Card Holder Name

Company Name:___________________________________
Address:__________________________________________

Authorized Account Holder Signature:____________________ Date_______________

Name as it appears on Credit Card:______________________________

Credit Card Number____________________________________________

Expiration date of credit card:______________Security Code of crecit card_____________________

Billing Address of Credit Card___________________________________________________________
Credit Card Type Visa Master Card American Express Discover

FAX COPY OF CREDIT CARD & THIS FORM TO 580.237.3278