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5711 Etheridge Street, Houston, TX 77087
www.nssihouston.com

Credit Card Authorization Form


Company Name:
Company Billing Address:
Company Billing City/State/Zip:
Company Phone No.:
Individual Authorizing Credit Card Charge(s) (Name):
PO/Invoice No.:
Name on Card:
Credit Card No.:
Expiration Date:
CVV/CVC No.:
Total Amount to be Charged:(Including All Taxes and Surcharges)



The undersigned authorizes Nuclear Sources & Services, Inc., NSSI/Recovery Services, NSSI to charge his/her credit card for the fees stated above. The undersigned agrees to pay for this purchase in accordance with the issuing bank cardholder agreement. The undersigned further understands and accepts that a 2.5% credit/debit card use convenience fee will be assessed NSSI, and added on all amounts charged by the cardholder on his/her credit/debit card.

Authorizing Signature
Date


Shipping Address: 5711 Etheridge Street, Houston, Texas 77087 Ph: (713) 641-0391
Fax: (713) 641-0392