Credit Card Form

State of the Art Plumbing Parts

Credit Card Authorization Form

Instructions:
1. Fill out this form on your computer screen and print it out
2. Sign where indicated
3. Submit by mail or fax to 1-800-882-7484

Submit to:
Dixie Plumbing Specialties, Inc.
PO Box 7237
Marietta, GA. 30065

Cardholder
Telephone
Email Address
I authorize a charge against my credit card in the following amount	$
Credit Card (choose one)	MasterCard-Visa
Card Number
Expiration Date		Security Code Visa and MasterCard use a 3 digit code on the back.
Billing Address
Signature: _____________________________________________________________