[vc_row][vc_column][vc_column_text css_animation=”left-to-right”]J & H Diesel Service, Inc. J & H Turbo Service, Inc.
P.O. Box 5278 3401 Hwy 82 East Greenville, MS 38704-5278 USA
Phone: 662-378-8711 FAX: 662-332-3561
Credit Card Authorization Form
Date:__________________
Billing Name: ___________________________________________________
Contact: _______________________________________________________
Billing Address: _________________________________________________
Billing City, State, Zip: ____________________________________________
Phone #: ________________________ Fax #:_______________________
Email Address: _________________________________________________
Ship to Name: __________________________________________________
Shipping Address: _______________________________________________
Ship to City, State, Zip: ____________________________________________
Credit Card: Master Card / Visa / American Express / Discover
Name on Credit Card: ____________________________________________
Card #: _________________________________ Exp Date: _____________
CCV#: _________ (Three digit Security code on back of card)
Total Amount: $____________________
I hereby authorize J & H Diesel / J & H Turbo to charge my credit
card for purchases as I have hereunder ordered.
__________________________________
Authorized Cardholder Signature
Internal use- Ref Invoice #:______________[/vc_column_text][/vc_column][/vc_row]