To submit your Credit Card information to our office for one-time or continuous payments please fill out the following form. This form must be completed in full and all information must be true and correct in order for your payment to be processed.

  

In lieu of my credit card imprint, I

  

 
   

(Name of Cardholder exactly as shown on Credit Card)

Hereby authorize Beach Pools, Inc. to charge my order to the following credit card

Please select your preferred Credit Card

  

  VISA Card  Master Card  Discover Card

Card Number

 

Expiration date

  

 

CVV2 Security Code

 

Billing Address as it appears on Credit Card Statement

Street address

  

 

Address (continued)

 

 

City

 

 

State

 

 

ZIP Code

 

 

Cardholder authorization

Payment Date

  

 

Payment Amount

  

 

Invoice number

  

 

Payment Option

 

Please check this box for one-time payment

 

 

Please check this box for continuous payments
   

 

Payment Cycle

 

Monthly  Quarterly  Bi-Yearly  Yearly

Please enter the shown validation code*

*Compulsory Subjects

By submitting this form for payment, I acknowledge acceptance of the Privacy Statement. I also agree to waive any charge-back rights and in the event of a dispute, request for a refund must be submitted in writing along with all order documentation in accordance with standard policy of company issuing credit card. I further acknowledge all information to be true and correct.

Submitting this form is not a receipt for payment nor will your credit card be charged you basically submit your information to our Billing Department - however payment will be initiated based on the information provided. Receipt will be the successful charge on your credit card which will be reflected on your credit card statement.