New Customers Auto Pay (Optional) To simplify the management of your account, we offer automatic payments via Visa, Master Card or American Express. If you choose to take advantage of this payment option, we must have authorization to process the charge. Complete this authorization form to setup your automatic payments. Your credit card can be processed by either option: Automatically process account balance on the statement date. Automatically process account balance on the 5th of each month unless I contact Peterson Dental Laboratory with a discrepancy on my statement. Please complete the pre-authorization form to utilize this method of payment. Select which processing option works best for you. Contact our Accounts Receivable Department with questions for additional information. ------------------------------------------------------------------------------PREAUTHORIZATION FORM: VISA, MASTERCARD or AMERICAN EXPRESSAll information must be completed to process card.Practice Name(Required) Dentist Name(Required) Please use this card for this account and any following account listed(Required) (Practices with multiple locations, accounts, or dentist)Cardholder's Name(Required) Office Address(Required) AddressCity(Required) CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP(Required)ZIPPhone(Required)Card Number(Required) CVV Number(Required) Expiration Date(Required) Options(Required) Option 1 - Automatically process account balance on the statement date. Option 2 - Automatically process account balance on the 5th of each month unless I contact Peterson Dental Laboratory with a discrepancy on my statement. Cardholder's Signature:(Required) TYPING YOUR FULL NAME IN THE FIELD BELOW CONSTITUTES A BINDING SIGNATURE ON THIS DOCUMENT
