Credit Card Authorization Form - Pre-Pay

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 all propane deliveries and service for the above referenced address.

I agree to charges to my credit card prior to the delivery of product or service and any amounts charged in excess of product or service amount will remain on account as a credit against future invoices, or refunded by check upon request.

Exact Billing Name and Address for Credit Card

Name:

Address:

City:

State:

Zip:

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 of Card Member:

Date:

Primary Phone:

Cell Phone:

E-Mail Address: