Credit Card Authorization Form Please enable JavaScript in your browser to complete this form.10501 NW 50th Street Suite No 102 Sunrise, FL 33351 (954) 541-5163 orders@parklandcollection.com LayoutEnter your Full Name *Enter your company name *, hereby authorize Parkland Collection LLC to charge my credit card account for purchases and incidental shipping charges or charges back billed to Parkland Collection. I authorize Parkland Collection to keep this card on file for all future purchases or order related incidentals mentioned above. Multiple Choice *VisaMaster CardAmerican ExpressDiscoveryName On Card *Credit Card Number *Layout1Expiration Date: *3-Digit VID Code: *Credit Card Authorization Form Street *Address Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateLayoutZip *PhoneLayoutFile UploadDate Your completion of this authorization form helps us protect you, our valued customer, from credit card fraud. Parkland Collection will keep all information entered on this form strictly confident Submit
