Credit Card Authorization

760 South Delsea Drive, P O Box 1447
Vineland, New Jersey 08362-1447
Phone: 856-692-7425 Fax: 856-696-7112
Visit us on the web at: www.ljzucca.com

I (Name): , as

(Title) for

(Company name)

hereby authorize L.J. Zucca Inc. to charge the credit card named below for purchasc(s) made to L.J. Zucca Inc.

CHECK ONE

This authorization is valid for this transaction only.

The transaction amount will be for exactly $

This is an open authorization to allow charges to the credit card for the balance due on my account for future orders.

CREDIT CARD INFORMATION

VisaMaster CardAmerican ExpressDiscover

( Last 4 Digits )Account Number:

Expiration Date:

CVV (code)

Account Holder's Name:

Account Holder's Phone:

Billing Address:

City:

State:

Postal Code:

I have read and agree to all the terms and conditions of this Credit Card Authorization page. I certify that I am the authorized account holder for this credit card. This payment authorization is for the purchase of tobacco and marketing material. I certify that I am the authorized account holder for this credit card and that I will not dispute the payment with my credit card company so long as the transaction corresponds to the terms indicated in this Credit Card Authorization page.

Authorized Account Holder Signature

Date: