Credit Card Authorization

Credit Card Authorization Form

* Indicates required field

Regal Account Number *

Company Name *

Phone Number *

Email Address *

Billing Address of Card *

Line 1

Line 2

City

State

Zip Code

Country

Name on the Card *

Card Type *

American Express

Number *

Expiration *

CVV Code *

Card Type *

Discover

Number *

Expiration *

CVV Code *

Card Type *

Master Card

Number *

Expiration *

CVV Code *

Card Type *

Visa

Number *

Expiration *

CVV Code *

The following employees are authorized to make charges to our account with Regal Decorating & Paint Center Inc. and consequently charges to the credit card(s) listed above.

Authorized Purchasers *

**The person signing this form indicates by signing that he/she has the authority to take such action on behalf of the account holder listed above. This authorization will remain in effect until revoked by the account holder evidenced by Certified Mail with return receipt requested. The account holder further agrees to absolve Regal Decorating & Paint Centers, Inc. of any liability for charges made by those listed above as Authorized Purchasers.

Signature *

Date *

Submit