1700 E. Walnut Ave
Fullerton, CA 92831
TEL: (714) 441-2893
TOLL FREE: (800) 749-0252
FAX: (714) 441-0525
sales@goodwaterwarehouse.com
4012 4St. SE
Calgary, Ab. Canada
TEL: (403) 252-7972
TOLL FREE: (888) 668-1234
FAX: (403) 252-3462
kjohnston@goodwaterwarehouse.com
ACCOUNT NUMBER:______________________________________________________ CONTACT:_______________________________________________________________ COMPANY MAILING ADDRESS:____________________________________________ CITY:________________________ STATE:_______ZIP CODE:________________ COUNTRY:___________________ TEL:____________________________ FAX:___________________________________ EMAIL:__________________________________________________________________
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| I HEREBY AUTHORIZE GOOD WATER WAREHOUSE, INC. TO CHARGE THE FOLLOWING CREDIT CARD(S) FOR MERCHANDISE SHIPPING OR INVOICES DUE OR PAST DUE. THIS INCLUDES ANY AMOUNT THAT IS READY TO SHIP ON CREDIT CARD TERMS, CREDIT LIMIT IS EXCEEDED AND/OR ANY INVOICE THAT IS NOT PAID WITH THE TERMS LISTED BELOW. |
CREDIT LIMIT:____________________________ TERMS:_______________ CREDIT CARD(S): (CIRCLE ONE) MC VISA DISC AM EX_________________________________ EXP. DATE: ______________ MC VISA DISC AM EX_________________________________ EXP. DATE: ______________ MC VISA DISC AM EX_________________________________ EXP. DATE: ______________ MC VISA DISC AM
EX_________________________________ EXP. DATE: ______________
PRINT NAME AS APPEARS ON CREDIT CARD: ______________________________________ AUTHORIZED CARD HOLDER SIGNATURE: ______________________________________ DATE: ______________________________ |