Royal Crest Dairy
350 S. Pearl St
Denver, CO 80209

Recurring Electronic Credit Authorization Form

In continuation of our efforts to bring more and varied services, we are pleased to announce that you can pay your monthly charges to us automatically with a Visa or Mastercard.  This system is widely used in other industries and has proven to be quite popular.  You will no longer have to write and mail us a check.  Simply complete the information below and mail to Royal Crest Dairy.

I hereby authorize a electronic credit card debit on the account designated below for the Royal Crest Dairy invoiced amount each month.  My account will be automatically debited by an electronic credit card transaction on the 10th of each month for as long as I am a customer of Royal Crest Dairy or I stop this process.  Your balance is always available on the first of every month.  All information you provide is strictly confidential.  Any adjustments on your account, need to be done no later than the 8th of the month 
PLEASE PRINT:
Customer #(if known):                          
Name On Account:
Service Address 1:
                                :     
City:                                                                   State:                           Zip:
Home Phone#:                                     Work Phone#:
Credit Card Billing Address:
Address:                                
City:                                                                   State:                           Zip:
Visa __  Mastercard __                                         Expiration Date ____/____/____
Credit Card Number ____________/____________/____________/____________
Credit Card Verification # ____
In accordance with credit card processing. I understand that any denied transactions will be collected on immediately and can cause a pause or cancellation of your home delivery.
Signature: __________________________________              Date: ____________________  
Please be sure to:   1)Fill in all the information required    2)Sign and date the form  3)Mail to: Royal Crest Dairy, 350 S. Pearl, Denver CO 80209 -- Attn: Account Services