Page 4 - Hensler-Assure ALL DMS Rapid Testing Billing and Purchasing Packet RV1
P. 4
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 Hensler Surgical to charge my credit card to collect my payments:
Signature: ____________________________________________________________
Name: ____________________________________________________________
Title: ____________________________________________________________
Date: ____________________________________________________________
