Van Vliet New york Group
  • 38-16 Skillman Avenue Long Island City, NY 11101 (Entrance is on 39TH Street)
    Tel: 718 - 786 - 0080
    Fax: 718-786-5997
    Email: support@vanvlietny.com

CREDIT CARD AUTHORIZATION FORM

PLEASE COMPLETE THE FOLLOWING TO AUTHORIZE CHARGE(S) FOR YOUR ORDER(S)

  • By checking the BLANKET AUTHORIZATION box, the customer authorizes J. Van Vliet New York LLC to charge all orders to the referenced credit card account for a period of one (1) year. For your records, copies of each charge to this account will be faxed or mailed / emailed to you.


  • Master Card
  • Visa
  • American Express
  • Discover


  • (if applicable or different from above)

  • (if applicable or different from above)

  • (if applicable or different from above)


The above signature authorizes payment by the referenced credit card account to J. Van Vliet New York, LLC.
PLEASE COMPLETE THIS FORM AND FORWARD IT TO THE ACCOUNTS RECEIVABLE DEPARTMENT.

FAX: 718-786-5997 / support@vanvlietny.com
Thank You!