Environmental Hazards Services, LLC ● 7469 Whitepine Rd.● Richmond, VA 23237 ● 800-347-4010
Environmental Hazards Services, LLC
CREDIT CARD AUTHORIZATION FORM
PLEASE FILL OUT COMPLETELY. ANY OMITTED INFORMATION MAY RESULT IN PAYMENT DENIAL
Company:_____________________________________________________ Account #__________________________________________
Contact Person:______________________________________________ Title:________________________________________________
Mailing Address ___________________________________________________________________________________________________
(street) (City) (State & Zip Code)
Phone: _____________________________________________Email:__________________________________________________________
Fax: _____________________________________________________________
PLEASE FAX THIS COMPLETE FORM ALONG WITH A
COPY OF BOTH SIDES OF YOUR CHOSEN CREDIT CARD TO:
1-804-275-3700
THIS SECURED FAX IS ONLY ACCESSIBLE TO OUR ACCOUNTING STAFF.
I authorize Environmental Hazards Services, LLC to charge the above credit card account for the purpose of
direct payment for all services, including shipping and handling, provided by The Laboratory. It is agreed that
The Laboratory will charge the credit card as service is provided. I understand and agree that if said credit card
account is revoked, suspended, cancelled, changed or rejected for any reason, my account will be charged a
service fee not to exceed $25.00. Notification of the same will be provided via telephone or fax immediately,
and the Client shall provide replacement information, in writing, within five (5) calendar days. A finance charge
of 1.5% per month will be applied to the outstanding balance due. In no event, however, shall fees exceed the
maximum lawful charges. All payments will be first applied to service fees, then finance charges, and then to
principal amount due. Should the account become 60 days past due, the account will be placed on credit hold
until the past due balance is paid in full. This authorization, which will be kept on file, shall remain in effect until
specifically revoked in writing.
___________________________________________ ______________________________________________
ENVIRONMENTAL HAZARDS SERVICES, LLC DATE CLIENT SIGNATURE DATE
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