New Customer Form

Business Name:

Business Address:

First Name:

Last Name:

Contact Email:

Contact Position:

Contact Cell Phone:

Accepted Cards:

Select Card Type:

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Credit Card #:

CC Expiration Date:

Name on Card:

CVV Code:

Credit Card Billing Address:

City:

State:

Zip Code:

Authorization for Credit Card on File

I hereby authorize Diagnos-Techs Inc, dba Angry Chef Kitchen Repair to process my credit card after services are rendered. I understand that I may or may not choose to use this card as the primary form of payment and that this credit card will also be used as a back-up form of payment if invoice terms are not met. I understand that in the event that payment terms are not met, my credit card will be charged automatically to keep my account in good standing. I understand that my information will be securely stored for future transactions on my account as necessary. I understand that it is my responsibility to review my invoices for accuracy prior to the charge date and that this authority will remain in effect until canceled by either party with 30 days written notice.

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Date:

Signature:

Caring Customer Service

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