EmailMe Form - American Textile Credit Card Authorization Portal

1. I give permission to American Textile & Supply, Inc. to charge my card for the following purchases. *
First Last
Buyer Name
Company Name
Contact Email
My card details will be stored in my profile and will only be used for approved purchases for
Please select at least one
2. Card Information:
All fields are required
Card type *
Master Card
Discover
VISA
AMEX
Other
*

Card Number

Protected in vault Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.
Cardholder (Name on card) *
First MI Last
Billing Address *

Street Address City State / Province / Region Postal / Zip Code
Recurring or One Time Charge *
3. One Time Charge Information (Optional)
One Time Charge Not to Exceed Limit
$ Dollars . Cents
4. Recurring Payments Information (Optional)
Any Individual Charge Not to Exceed Limit
$ Dollars . Cents
Additional Comments
Customer Signature
Clear
Date:
MM / DD / YYYY
Your completion of this authorization form helps us protect you, our valued customers, from credit card fraud.
All information entered on this form will be kept strictly confidential by American Textile & Supply, Inc.
It is used solely for credit card authorization purposes.

Thank you!