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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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Last modified: 10/18/09