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 if you'd like to pay via this manner.
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Email *
Company Name *
Authorized Purchasing Agents (List All Here) *
Company Phone # *
Main E-Mail Address *
Alternate E-Mail Address
Billing Address (#, Street, City, State, Zip) *
Shipping Address (#, Street, City, State, Zip) *
Card Payment Type *
Credit Card Number (Last 4 Digits Only) *
Full Name on Card *
Name of Person Filling Out Form *
Print Name of Person Approving Use of Card *
Typing your Initial Acts as a virtual Signature *
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 for this transaction and any and all future transactions.
Do you Agree or Disagree? *
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This form was created inside of Excelerate Performance.