Ruddock Shirts

PO Box 10205          El Paso, TX 79995

(915)544-3530    Fax (915)544-9460

Easy Pay Credit Card Consent

**Please see terms on your Order Form**

I authorize Ruddock Mfg to charge  my

__    Discover

__    MasterCard

__    Visa

__    American Express

• One time charge of $ _______________ to pay invoices ______________________________

• Monthly charge of $ _______________ per month for  _____ months starting _____________

• Authorization to charge my card for all shipments beginning ________ and ending _________, not to exceed $_____________ per shipment

Company  _______________________________  Customer Number:  ______________

Cardholder's Name  _______________________________

Card Number  _______________________________

Expiration Date  _____________

Billing Address  _______________________________

                        _______________________________

                        _______________________________

Phone Number:  (___)_____-________

Cardholder's Signature  _______________________________