Form Testing Credit Card Authorization Form Credit Card Authorization Form "*" indicates required fields Consent* I agree to these terms.I give permission to Mason’s Propane Service LLC to charge my card for the following purchases. My card details will be stored in my profile and will only be used for approved purchases. Mason’s Propane Service is not responsible for any overdrafts or overdraft fees caused by the automatic draft.Customer Name* First Last Cardholder Email* Propane / Propane related Service work (if applicable)*Product/ ServiceCard Type* Mastercard Discover Card Visa American Express Cardholder* First Middle Last (Name on card)Card number*This value will be encryptedExpiration date* MM slash DD slash YYYY This value will be encryptedZip code*(From credit card billing address)Charge every:* When propane is delivered On the due date Weekly Bi-weekly Monthly Custom (you specify) Receipts through the online customer portal* Yes No Mail Receipts? Yes No Email Receipts?* Yes No Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Charge on this date:*(For example, the 1st of every month)Payment Amount*Payment AmountPropane / Propane related Service work (if applicable)*Product/ service soldTo cancel, contact: Billing department 717-259-0624, email [email protected], or mail P O Box 338, Thomasville, PA 17364. Cancelations must be received within 72 hours (3 days) prior to expected billing date.Consent* I agree to the Terms of agreementName* First Last Date* MM slash DD slash YYYY Account Number*This value will be encrypted
