Credit Card Authorization

Submit your credit card information online! Just fill out the form below and it will be sent directly to us. Please allow 1-2 business days for processing.

Your credit card information is for one time use only. No records will be saved in our database.

Company Information

Company Name

Contact Name

Contact Email Address

Contact Phone

Order Information

Charge amount does not include freight and tax*. They will be applied once your order ships.
*Sales tax can be removed with a resale certificate. Please attach the certificate below, or email it to accounting@primalighting.com

Purchase Order Number

Charge Amount

Prima Sales Order Number (if available)

Attachment

Comments

Creditcard Information

CVV Code location for Visa/Master/Discover cards is on the back of the credit card. For American Express, it is on the top right-hand corner.

Card Number

Card Type

VisaMaster CardAmerican ExpressDiscover

Expiration Date (MM/YY)

CVV Code

Billing Information

Billing information for cardholder must match address on bank statement exactly.

First Name

Middle Initial

Last Name

Address Line 01

Address Line 02

City

State

Zip Code

Shipping Information

If Shipping Address is the same as Billing Address, please leave it empty.

First Name

Middle Initial

Last Name

Address Line 01

Address Line 02

City

State

Zip Code

The cardholder agrees that by checking "I agree to the terms and agreements", they are agreeing to pay all charges issued to the cardholder, including a 3% surcharge for any non-prepaid orders and/or orders over $2,000. I understand that the amount charged to the cardholder's credit card account may be reflected on the cardholder's balance prior to shipment(s).

Submit your credit card information online! Just fill out the form below and it will be sent directly to us. Please allow 1-2 business days for processing.

Your credit card information is for one time use only. No records will be saved in our database.

Company Information

Company Name

Contact Name

Contact Email Address

Contact Phone

Order Information

Charge amount does not include freight and tax*. They will be applied once your order ships.
*Sales tax can be removed with a resale certificate. Please attach the certificate below, or email it to accounting@primalighting.com

Purchase Order Number

Charge Amount

Prima Sales Order Number (if available)

Attachment

Comments

Creditcard Information

CVV Code location for Visa/Master/Discover cards is on the back of the credit card. For American Express, it is on the top right-hand corner.

Card Number

Card Type

VisaMaster CardAmerican ExpressDiscover

Expiration Date (MM/YY)

CVV Code

Billing Information

Billing information for cardholder must match address on bank statement exactly.

First Name

Middle Initial

Last Name

Address Line 01

Address Line 02

City

State

Zip Code

Shipping Information

If Shipping Address is the same as Billing Address, please leave it empty.

First Name

Middle Initial

Last Name

Address Line 01

Address Line 02

City

State

Zip Code

The cardholder agrees that by checking "I agree to the terms and agreements", they are agreeing to pay all charges issued to the cardholder, including a 3% surcharge for any non-prepaid orders and/or orders over $2,000. I understand that the amount charged to the cardholder's credit card account may be reflected on the cardholder's balance prior to shipment(s).