Watcon Credit Authorization

Please fill in the information requested and fax this form back to Watcon at (360) 692-2285.

I authorize Watcon to debit my credit card: ---$_________________________

Date: _____________________________

For the following: __________________________________________________________________________
(description of items)

Credit Card # ______________________

Type of card; _________________

Expiration date: __________________

Card member Name: __________________________________________

Card member telephone number ______________________________

Card member Billing Address:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Signature of Card member: ___________________________________________