Credit Card Authorization Form - Autocharge

Date:

To:

Credit Department
New England/Greenwich Propane
162 Grassy Plain Street
Bethel, CT 06801

Please take this authorization to automatically charge my credit card listed below for all current and future propane deliveries and service to:

Customer Account#:

Name:

Address:

City:

State:

Zip:

Exact Billing Name and Address for Credit Card

Name:

Address:

City:

State:

Zip:

I am aware that my account will become "autocharge" and the credit card below will be charged within 1-3 days from delivery or service. To stop automatic billing, I understand that a thirty day notice is required.

Credit Card # (Mastercard or VISA Preferred): Enter the LAST 4 digits of your credit card below and call the office at 203-792-7654 after this submission to give your full credit card number.

LAST 4 Digits of Card:

Expires:

CCV Code:

Signature:

Date:

Primary Phone:

Cell Phone:

E-Mail Address: