New England Wholesale Florist
Credit Card Authorization Form

I, ___________________ authorize New England Wholesale Florist Supply to charge my credit/debit card for product & services rendered at the time of sale.  I acknowledge orders may not be sent if the below card declines for any reason, unless prior payment arrangements are made.

Company Name: 
Owner Name:
Street/Billing Address: 
Company Phone: 
Fax: 
Tax Resale Number: 
Email Address: 
Card Type:
Card Number:
Card CV2:
Expiration Date: 
Billing Address:
Billing Zip Code:
Name on Card:

Owner's Signature:                                                         Owner's Name:

_________________________________________________________________________________ 
								           (Please Print)
Date:

          __________________

        Fax this form completed to (203) 630-0777 or email it to Office@NewEnglandFlorist.com 
          If sent thru email - this form must be signed in person before your 1’st order will ship.