Credit Card Authorization
This purpose of this form is to establish an authorization by approved personnel to charge your credit card for purchase orders you submit. With your approval we will securely store your credit card information with the merchant processor. All information will remain confidential and accessible only to those authorized to charge credit cards at Excelerate LLC.

Once you have filled out this form please call Joshua 203-483-6100 ext: 111 to provide your credit card information which will securely be entered in the merchant processor’s database.

We can also process payments via ACH with Quickbooks. Please inquire via email to joshua@excelerateperformance.com if you'd like to pay via this manner.

Email address *
Company Name *
Your answer
Authorized Purchasing Agents (List All Here) *
Your answer
Company Phone # *
Your answer
Main E-Mail Address *
Your answer
Alternate E-Mail Address
Your answer
Billing Address (#, Street, City, State, Zip) *
Your answer
Shipping Address (#, Street, City, State, Zip) *
Your answer
Card Payment Type *
Credit Card Number (Last 4 Digits Only) *
Your answer
Full Name on Card *
Your answer
Name of Person Filling Out Form *
Your answer
Print Name of Person Approving Use of Card *
Your answer
Typing your Initial Acts as a virtual Signature *
Your answer
Agreement
As the above signed credit card holder, I hereby authorize Excelerate LLC to charge the credit card I will provide via phone. The last 4 digits of this credit card are listed above on this form. This card will be used for purchases transmitted verbally, by phone, by email, or otherwise, and I authorize all charges related to my order, including parts cost, all applicable taxes, fees, and shipping and handling charges. I also authorize Excelerate LLC to charge any open balance on my account for any part or service rendered at the time of the transaction.

I further agree that all orders transmitted to Excelerate LLC verbally, in writing, or electronically will be fulfilled (and charged to the above card) unless officially canceled in writing prior to shipping. Order cancellations must be made in a timely manner, and be followed by a confirmation from Excelerate LLC. Unconfirmed cancellations will not interrupt order fulfillment or credit card charges. Fees may be incurred for any cancellation. I hereby accept full responsibility for all costs resulting from improper order cancellation and/or credit card charge backs, fraudulent or otherwise.

Terms and Conditions
I have read and agree to be bound by Excelerate LLC’s policies, terms and conditions, and instructions, which can be found at https://www.excelerateperformance.com/terms-and-conditions for this transaction and any and all future transactions.
Do you Agree or Disagree? *
Required
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