Credit Card Authorization Form

Cardholder Email*

Propane / Propane related Service work (if applicable)*

Product/ Service

Card number*

This value will be encrypted

Expiration date*

This value will be encrypted

Zip code*

(From credit card billing address)

Email*

Charge on this date:*

(For example, the 1st of every month)

Payment Amount*

Payment Amount

Propane / Propane related Service work (if applicable)*

Product/ service sold

To 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.

Date*

Account Number*

This value will be encrypted

Credit Card Authorization Form

Mailing Address

Office Location

Contact us

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