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Credit Card Authorization Form

Your completion of this authorization form helps us to protect you, our valued customers. All information entered onto this form will be kept strictly confidential.

Directions:
1. Complete the credit card authorization form details below. Cardholder must accept this form by hitting the submit button. We reserve the right to verify the provided information with the issuing bank.
2. If you prefer to fax or email the form, you may download a copy here. Via fax, our fax number is 866-576-5236 or email at customerservice@poly-lumber-furniture.com

Billing Address

Credit Card Information

  • ** By completing and submitting this form, you are authorizing Premium Poly Patios to charge your card for purchases made through our store. Cardholder is responsible for providing accurate all card details on this form.

* Required Fields