Boutique Wholesale Payment Method Authorization
Business/Account Information
Business Name
Contact Person
Email Address
Phone Number
Billing Address
Payment Method
Authorized Payment Method
Credit Card
Debit Card
ACH/Bank Transfer
Other
Account/Cardholder Name
Account/Card Number
Expiration Date (MM/YY)
Routing Number (ACH Only)
Authorization
By signing below, I authorize Boutique Wholesale to charge the above account by the specified payment method for all approved purchases and invoices.
Authorized Signature
Date