Credit Card Authorization Authorization for automatic credit card transactions Name First Last Billing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Card Number* PLEASE INCLUDE DASHESExp. Date CVV* Debit or Credit Debit Credit Card TypePlease SelectVisaMasterCardDiscoverAmerican ExpressSignature*Date Submitted MM slash DD slash YYYY Email* Consent* I agree to the terms and conditions.By signing below I hereby authorize the Ellsworth Farmers Exchange to automatically charge my credit card for my monthly purchases. In exchange for this authority, I understand that I will be eligible for any prompt payment discounts in effect at the time. Further, I understand that it is my responsibility to provide the Ellsworth Farmers Exchange with a valid credit card number, CV2 code* and expiration date and that I may forfeit any available discount if my credit card on record is declined.