Credit Card Authorization Form - One Time Charge

Date:

To:

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

Please take this authorization to charge my credit card listed below:

Customer Account#:

Name:

Address:

City:

State:

Zip:

Exact Billing Name and Address for Credit Card

Name:

Address:

City:

State:

Zip:

At this time I am requesting a dollar amount of to be charged to this credit card. I am aware that a new form is required for each requested charge and one time charge requests will be processed upon receipt of signed form (same day or next day).

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: