State of the Art Plumbing Parts
Credit Card Authorization Form
Instructions:
1. Fill out this form on your computer screen and print it out
2. Sign where indicated
3. Submit by mail or fax to
1-800-882-7484
Submit to:
Dixie Plumbing Specialties, Inc.
PO Box 7237
Marietta, GA. 30065
Cardholder
Telephone
Email Address
I authorize a charge against my
credit card in the following amount
$
Credit Card (choose one)
MasterCard-
Visa
Card Number
Expiration Date
Security Code
Visa and MasterCard use a 3 digit code
on the back.
Billing Address
Signature:
_____________________________________________________________
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Copyright © 2010 Dixie Plumbing Specialties
Last modified: 05/28/10
State of the Art Plumbing Parts 
