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Credit Card Authorization Form

I, ___________________________________________ , hereby authorize Poly Bag Planet, Inc, to charge my credit card for the amount invoiced. Customer Company Name: ______________________________________________ DISCOVER VISA MasterCard

Credit Card Number: _______________________________________________________

12 2016 Expiration Date: _____ /______

Credit Card Billing Address:

SEC Code: ____________

Street: ____________________________________________________________________ City:________________________________________________ State: _____________ Zip Code: ___________ Telephone: ( _________ Country: _________ ___________

) _____

Email: __________________________________

Cardholder's Signature

______________________________________________

Date

____________________________________

PLEASE FAX THIS FORM TO: 1-877-722-7079

As the credit card holder, I also authorize Poly Bag Planet, Inc. to charge my credit card for future purchases verbally (or written) approved by me. Your completion of this authorization form helps us to protect you, our valued customers, from credit card fraud. Poly Bag Planet, Inc. will keep all information entered on this form strictly confidential.

PO BOX 63, Pleasant Valley, IA 52722 www.PolyBagPlanet.com

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