KLIM INDUSTRIAL INC.
244 N. RANDOLPHVILLE RD.
PISCATAWAY, NJ 08854
Fax: 732-752-9101
Credit Card Authorization Form

Company Name:
Purchase Order #:
Authorized amount:
(Amount may change due to shipping and handling)
Credit Card Information (Please print)
VISA MASTERCARD
Credit Card Number: - - -
CVC2 (Card Verification Code)/CVV2 (Card Verification Value):
Expiration Date: / /
AMERICAN EXPRESS
Credit Card Number: - - -
CID (Card Identification) (4-digit number on front of card):
Expiration Date: / /
Cardholder’s Name:
Billing Address:
City: State: Zip:
Phone:
 

I understand that order will not be processed until form is returned to
Klim Industrial, Inc.
 

Cardholder Signature: ________________________________________
Date: