Credit Card Authorization Form - Security Deposit

We require this form to be on file if you are requesting your bills to be charged to your credit card.

Date:

To:

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

Customer Account#:

Name:

Address:

City:

State:

Zip:

Please take this authorization to automatically charge my credit card listed below for a security deposit of $ on my account:

I understand that this deposit will remain on my account until the account is closed. If there is a zero balance upon closing, the security deposit will be refunded by check. If there is an outstanding balance upon closing, the security deposit will be applied to any open invoices and any remaining balance will be refunded.

Exact Billing Name and Address for Credit Card

Name:

Address:

City:

State:

Zip:

Credit Card # (Mastercard or VISA): 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 of Card Member:

Date:

Primary Phone:

Cell Phone:

E-Mail Address: