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MEMPHIS FENCE COMPANY, INC. 
1380 NORTH WILLETT ST. - MEMPHIS, TN 38108 - (901) 278-9710

Credit Card Authorization Form

I, ___________________________________________ , hereby authorize MEMPHIS FENCE COMPANY, INC., to charge my credit card account in the amount not to exceed: $_________________

( ) VISA ( ) MasterCard ( ) American Express ( ) Discover

Credit Card Number: _______________________________________________________

Expiration Date: _____ /______ VID Code: ____________

Credit Card Billing Address: Street: ______________________________________________________________ 
City:____________________ State: _________Zip Code: ________ - _________
Country: (if not US) _________________________ 
Telephone: ( ) _____- _________

Requested Shipping or Job Order Address: Street: ______________________________________________________________ City:___________________State: _________ Zip Code: ________ - _________ Country: (if not US) _________________________ 
Telephone: ( ) _____- _________

As the credit card holder, I hereby authorize receipt of goods & services at the shipping address above.

___________________________________________ ____/____/______ Cardholder's Signature Date

As the credit card holder, I also authorize MEMPHIS FENCE COMPANY, INC., to charge my credit card for future purchases verbally approved by me. Authorization Valid Until: ______ / ______ Initials Here: _______________

Your completion of this authorization form helps us to protect you, our valued customers, from credit card fraud. MEMPHIS FENCE COMPANY, INC, will keep all information entered on this form strictly confidential.