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George Propane address
Credit/Debit Card Auto Charge Authorization

Thank you for agreeing to pay your bill by credit/debit card.

Your completion of this authorization form helps us to protect you, our valued customer, from credit card fraud. All information entered on this form will be kept strictly confidential by George Propane, Inc.

PREFER TO FILL THIS CREDIT/DEBIT CARD AUTHORIZATION OUT BY HAND?
CLICK HERE FOR A PDF TO PRINT/SEND VIA FAX OR MAIL

1. Please fill out this credit/debit card automatic charge authorization in full. NOTE: *Required Field.
2. Read the Authorize Transactions & Conditions then click the agree check box.
This will then turn on the SUBMIT button.
3. Click the SUBMIT button on the bottom to submit the final form.
NOTE: You will be sent to a Thank You page when your application is successfully submitted.

 

Customer Applicant

Mailing Address

Card Billing Name & Address

  

 

TERMS & CONDITIONS: I hereby declare that the credit or debit card information above is true, accurate and appears in the name as stated.

I hereby authorize George Propane, Inc. to initiate entries to my account in the manner indicated and charge my credit or debit card account following each delivery of propane and/or upon receipt of an invoice for service. I am aware that I will receive a copy of the charge slip or paid invoice, which will act as my record of this transaction.

Further, I authorize my credit or debit card company to accept and to charge my account purchases. I understand that my propane delivery and/or service invoice amounts will be transferred from my credit or debit card until George Propane, Inc. receives further instructions from me.

I Agree with the above terms:

Before submitting please make sure of the following

  • All necessary information has been filled out.
  • All information is error-free
  • All information is correct and fraud-free.
  • For Fraud Prevention purposes, we have recorded your IP Address & the time of your submission.

* required information