AUTHORIZATION PAYMENT BY TELEPHONE

Tel: (506) 634-7275
Toll Free: (866) 634-7275
Fax: (506) 634-8398

DATE *

TO WHOM IT MAY CONCERN

AUTHORIZATION - PAYMENT BY TELEPHONE

I hereby authorize Park Fuels Ltd. to process payments from time to time for the purchase of my fuel oil and related services upon my request/authorization by telephone.

CUSTOMER ACCOUNT NAME *

CUSTOMER ACCOUNT NUMBER *

CARDHOLDER NAME *

CREDIT CARD COMPANY *

I HAVE A VISA

I HAVE A MASTERCARD

CARDHOLDER # *

CARD EXPIRY DATE *

CVC # (3 DIGIT NUMBER ON BACK OF CARD) *

MAILING ADDRESS FOR CARD *

POSTAL CODE *

This agreement remains in effect until cancelled in writing.

AUTHORIZED CARDHOLDER SIGNATURE

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Type It
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DATE *