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Authorization To Use Credit Card

Date: _________________________________________________

Name: ________________________________________________

Name of Cardholder: _____________________________________

Type of Credit Card: _____________________________________

Credit Card Number: _____________________________________

Expiration Date: _________________________________________

This is to verify that I have authorized Pool Mart to run the above named credit card for payment of services and/or chemicals for my swimming pool.

Signature: _____________________________________________

Service Address: _______________________________________

Billing Address: ________________________________________

Home Phone: __________________________________________

Cell Phone: ___________________________________________