Credit Card Authorization Form

Thank you for choosing Byrd’s Inert Landfill, Inc. for your disposal needs. Please complete this application to establish a charge account with us. All charge accounts must adhere to our payment terms, detailed below.

Customer Information

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Your Credit Card Authorization has been sent

Company Name

Contact Person

Phone Number

Email Address

Street Address

City, State, Zip

Credit Card Information

Cardholder’s Name (as it appears on the card)

Credit Card Number

Expiration Date (MM/YY)

Card Type(required)

Visa

MasterCard

American Express

Discover

Authorized Signature

Printed Name

Date (YYYY-MM-DD)

Authorization Terms (required)
I, the undersigned, authorize Byrd’s Inert Landfill, Inc. to process payments using the method selected above, subject to the following terms: 1. Payments will be processed in accordance with Byrd’s Inert Landfill, Inc.’s billing terms. 2. This authorization will remain in effect until written notice of cancellation is received. 3. I agree to notify Byrd’s Inert Landfill, Inc. immediately of any changes to my payment information. 4. Balance Cap: If the account balance reaches $5000 before the billing cycle ends, payment is due immediately. 5. I acknowledge that my account must remain in good standing and understand that any issues with processing payments may result in suspension of service.

Byrd's Inert Landfill

Where dumping is our main priority

Credit Card Authorization Form

Customer Information

Your Credit Card Authorization has been sent

Customer Information

Your Credit Card Authorization has been sent

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