Credit Card Form
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BC Onsite Sewage Association
Box 101 – 6450 Island Hwy Nanaimo BC V9T 1X2 Phone: 1-250-758-8442 Fax: 1-250-758-8448 |
Credit Card Authorization Form
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Customer to complete:
I, ___________________________________________, hereby authorize the BC Onsite Sewage Association to charge my credit card for goods or services rendered by:
in reference to either (Enter company name)
(a) Invoice Number: or
(b) Project Description :
Amount: $ Card Type: o Visa o Mastercard
Name as it appears on credit card:
Card Number: Exp Date:
Customer Signature:
Merchant ID# 8018984875
Pre Authorization Tel # 1-866-508-5855
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BCOSSA Member to Complete:
Cheque to be made Payable to:
Mailing Address:
City: Province: Postal Code:
Phone: Fax: Email:
BCOSSA Member Name:
By signing below, I understand that 3.39% of total transaction will be retained by BC Onsite Sewage Association to cover administration fees, and that payment will be mailed to me within 15 business days of delivery to the BCOSSA office.
Member Signature: Date: Fax to: 1-250-758-8448 or email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it |