Form is successfully submitted. Thank you!Credit Card Authorization FormAuthorization for automatic credit card transactionsBy 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.Name:Billing Address:City: State: Zip:Card Number (PLEASE INCLUDE DASHES) and CV2 CodeDebit or CreditDebitCreditCard Type*Please selectVisaMasterCardDiscoverExpiration Date*month/yearSignature: (type the name of the person submitting form here)Date SubmittedEmail address: SubmitPowered by ARForms
