Please print out and complete this form, then return it by FAX to 301-773-9872. 
 

I hereby authorize Taylor Equipment Distributors, Inc. (Taylor AFS) to charge my credit card account
for products or services as provided.  Copies of all credit card transaction receipts will be provided.
All credit card information will remain confidential.

Location/Business Name_______________________________________________

Street: ______________________________________________________________________

City:________________________________________________ State: ___________________

Zip Code: ___________ - _________                                       Telephone: (         ) _____   -   _________

Credit Card:  (  ) VISA (  ) MasterCard                       Expiration Date: ______ /______

Name on Credit Card ___________________________________________________________

Credit Card Number: ______________________________________ Security Code __________

Credit Card Billing Address (if different from above):

Street: ____________________________________________________________________

City:________________________________________________ State: _________________

Zip Code: ___________ - _________       Telephone: (         ) _____   -   _________

Fax Credit Card Transaction Receipt to Fax Number: (         ) _____   -   _________

Cardholder's Signature____________________________ Date _____________

Cardholder's Email: _______________________________________________  

If you have any questions please contact Accounts Receivable at 301-773-2700.