CC Authorization Form

Casa Redimix Concrete Corp.

*For All Your Concrete Needs*

866 Edgewater Road    Tel:  718 589 1555

Bronx NY 10474 Fax: 718 842 0443

Telephone Credit Card Authorization From

To:

Company:

Fax:

Tel:

From:

Subject:

I         Hereby authorize Casa Redimix Concrete Corp. (*Casa*) to charge my credit card for any purchases for material or payments to my Casa House Credit Account made by telephone. I affirm to Casa that I have the right to use this credit card for said purposes.

Amount of Charge $:

Credit Card Type:

Credit Card#:

Expiration Date:

Three Digit Security Code:

Name on Credit Card:

Billing Address:

City:

State:

Zip Code:

Telephone:

Return Fax to

1. Identification is required. In additional to faxing this from you must also copy of the front and back of your credit card and a copy of your driver's license.

2.  I or my agents have examined the good and services purchased and they are free of defects.

3. I understand and agree to the Casa's refund policy that all returned goods must be accompanied by the Invoice and subject to 25% handing charge. Refunds will be issued only for store credit. All returned goods must be original condition. Absolutely no returns after thirty days for any special order item(s) or item(s) that was/were ordered and not in yard stock.

4. I understand that credit card payment will be accepted for invoices less than thirty (30) day's old no, charge and a fee of 3% will be added to my charge payment for invoice over thirty (30) day's.

5. I agree to pay the total amount according to the credit card issuer agreement. I do understand if I reverse the charge, for any reason whatsoever, I will be liable for all collection costs incurred by Casa to recover the amount in addition to the amount of the invoice.

Print Name:

VISA
MASTER CARD
AMERICAN EXPRESS
DISCOVER

*I have read and agree to the above.