Collins DISH Retailer Application - Page 4

CREDIT AUTHORIZATION

CREDIT AUTHORIZATION

BLANKET CREDIT CARD AUTHORIZATION Collins Distribution accepts certain credit cards as acceptable payment . They include Visa , MasterCard , American Express and Discover . In order for Collins Distribution to accept a credit card as a form of payment , each credit card requires the following information and signature of approval by the credit card holder .
• Individual cardholder must be a Principal / Owner / Partner listed on page 2 of this Retailer Application .
• No consumer credit cards will be accepted . Fill out the following information for each credit card you authorize for purchases :
CREDIT CARD INFORMATION 1st Type of Card ( check one ): ____ ____ ____ Acct #: ________________________________________________________________ Name as it appears on the card : ______________________________________________
Expiration Date : ________________ Billing Address as it appears on your statement ( city , state , zip ): _____________________________________________________________________________________ Authorized Buyers : In addition to myself , I hereby authorize the following individuals listed below to provide written or verbal approval to Collins Distribution on all purchases related to the credit card listed above . # 1 ____________________________________________ # 2 ____________________________________________
2nd Type of Card ( check one ): ____ ____ ____ Acct #: ________________________________________________________________ Name as it appears on the card : ______________________________________________
Expiration Date : ________________ Billing Address as it appears on your statement ( city , state , zip ): _____________________________________________________________________________________ Authorized Buyers : In addition to myself , I hereby authorize the following individuals listed below to provide written or verbal approval to Collins Distribution on all purchases related to the credit card listed above . # 1 ____________________________________________ # 2 ____________________________________________
I , ______________________________________________________ hereby authorize payment for equipment , chargebacks and wholesale product orders purchased from Collins Distribution . I understand that the credit card listed on this form will be charged for said purchases based on verbal and / or written approval from the signatory or the listed authorized buyers above . I further realize that it is my sole responsibility to notify Collins Distribution in writing if I wish to remove or amend an authorized buyer or the card itself . Notification should be provided via fax to 765-668-2708 .
Signature : ___________________________________________________________________________________________________ Date : _____________________
CREDIT AUTHORIZATION To Whom It May Concern : I hereby give my permission and authorization for the release of credit and banking information to Collins Distribution . This authorization is valid for both business and personal , credit and banking purposes . The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race , color religion , national origin , sex , marital status , age ( provided the applicant has the capacity to enter into a binding contract ); because all or part of the applicant ’ s income derives from any public assistance program ; or because the applicant in good faith exercised any right under the Consumer Protection Act . The federal agency
that administers compliance with this law concerning this creditor is the Federal Trade Commission , Washington D . C .
The information below must be completed by Principals , Partners or Owners only .
# 1 Name : ____________________________________________________________ Title :______________________________________ Date : _________________ Signature : ___________________________________________________________
SSN : ____________________________________________________________
# 2 Name : ____________________________________________________________ Title :______________________________________ Date : _________________ Signature : ___________________________________________________________
SSN : ____________________________________________________________
# 3 Name : ____________________________________________________________ Title :______________________________________ Date : _________________ Signature : ___________________________________________________________
SSN : ____________________________________________________________
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