Page 17 - Hensler Surgical - Biosciences COVID Rapid Testing Proposal - Facility_Clinic_Hospital - 5_6_2020
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Credit Card Authorization Form
Credit Card Type: Circle One
Card Number: ____________________________________________________________
Expiration Date: _______ / 20 _____
CSV #: _______
Name on Card: ______________________________________________________________
Billing Address: ______________________________________________________________
Suite / Building #: ______________________________________________________________
City: _________________________ State: _______________ Zip: ___________
I hereby authorize BioLab Sciences to charge my credit card to collect my payments:
Signature: ____________________________________________________________
Name: ____________________________________________________________
Title: ____________________________________________________________
Date: ____________________________________________________________
