csg-cc-auth-form

Chandler’s Site to be Used

Name of Company

Phone / Contact Number

Email

Credit Card Number

Expiration Date

CV #

Credit Card Billing Address

Date to be Used

Amount of Loads / Tonnage

Job Site Address

Driver’s Authorized to Sign Card

*I hereby authorize Chandler’s to use this credit card for payment for Loads brought to and/or Material Purchased from any of the Chandler’s Site. I authorize the above driver(s) to sign for the receipt and ticket for the purchase of the loads/material at the Chandler’s site. 3% CREDIT CARD FEE WILL BE ADDED PER TRANSACTION.

Customer Name

Date