Credit Card Authorization Form

    Credit Card Billing address:

    Mailing address:

    I authorize CANADA PLASTICS AND BELTING INC. to sign any customer credit card authorization on my behalf, and intend such signature to bind me the same as if I had personally signed, and charge those purchases to my credit card account. I will not charge back and waive any and all rights to charge back, cancel or dispute the charges. I agree to pay such purchases and will not hold CANADA PLASTICS AND BELTING INC. responsible for any of its action pursuant to this credit card authorization form. By signing this form the cardholder has given CANADA PLASTICS AND BELTING INC. full authorization to verify name, address and credit card number with the bank or credit card company. By signing this form, card holder acknowledges that this form is replacing credit card imprint form which card holder cannot sign due to distance issues and request credit card company to accept it in lieu of an imprint form.