R&H Wholesale Supply, Inc.

To pay with a credit card: 1) fill this form out. 2) print it and sign it. 3) fax it to 415-641-0455 *Our Policy is to have your signature on file. Note: Your credit card information is not being transmitted over the internet.
Business Name:
Account Number:
Credit Card Type:
Exact Name on Credit Card:
Credit Card Number:
Last 3 numbers (back of card):	(V code) (For American Express 4 on front)
Expiration Date:	mm/yy
Billing Address of Card:
Billing Zip Code of Card:
Use this card for all future online purchases?:	Yes No
Phone Number:

Signature: _______________________________Date: _________________