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Fill out this form to authorize payments by credit card upon request. This information will be stored in strict confidence for future use.

* Email Address
Email address of individual submitting this form.
* Date
* Customer Number
Your account number with Continental Flowers
* Credit Card Type
Master Card VISA American Express
* Cardholder Name
* Card Number
Please fill this field without dashes or spaces.
* Billing Address
Include city, state, and ZIP
Signature
Sign this field using all uppercase to guarantee authenticity