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About
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Marine Services
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Forms & Documents
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Contact
Phone : 718-981-4600
Email : dispatch@cwofny.com
Credit Card Authorization Form
Company Name:
Cardholder Name:
Credit card billing address:
Telephone:
Email Address:
Credit card Number
Type of Card:
VISA
Mastercard
AMEX
Security Code (CVV):
Expiration
date
Amount authorized:
Authorization valid to (date):
Reason for Payment:
Comments or Special Instructions
Cardholder’s Signature:
Date:
Send
