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Credit Card Authorization for Purchase / Charges:    

Pay to: 

RubberLine, Inc.

            PO Box 340

            Muenster, Texas 76252

Phone:  940-759-2986

FAX:      940-759-4288  

Customer Information:  

            _________________________________

            Cardholder  

            _________________________________

            Name of Company  

            _________________________________

            Mailing Address  

            _________________________________

            City                                            State                       Zip  

            _________________________________

            Telephone  

            _________________________________

            FAX  

            [   ] Visa    [   ] MasterCard        [   ] American Express     [   ] Discover  

      __  __  __  __     __  __  __  __     __  __  __  __     __  __  __  __

            Credit Card Number        

            Expiration date ____ / ______  

            Amount of Purchase / Charges $ ______________  

            Purchase / Charges is for:        

             __________________________________

              Today’s date ____ / ____ / 20 ___  

            __________________________________

            Signature  

Instructions:  Please fill in all information, date and sign the              authorization then FAX to 940-759-4288

RubberLine, Inc.    Phone: 940-759-2900    Fax: 940-759-4288
885 North Ash Street    P.O. Box 340    Muenster, TX 76252
www.rubberlineinc.com             sales@rubberlineinc.com

For your convenience, RubberLine ACCEPTS these major credit cards!