Credit Card Payment Form

Holland 1916 does not retain credit card information. We use an outside vendor (www.authorize.net) for
processing credit card transactions and have confirmed they do retain your credit card information after your
transaction is complete. A 3% fee is added for processing all payments made by credit card. For your
convenience Holland 1916 companies also accepts payments by ACH/EFT or wire transfer to our bank. Checks
may be sent to our lockbox addressed according to the invoicing company Holland Nameplate Inc, PO Box
411184, Kansas City, MO 64141 OR Holland Interface Solutions Inc. PO Box 410485, Kansas City, MO 64141.

Credit Card Information *

Card Number

Expiration

Security Code

Payment Amount (USD) *

Invoice #

PO #

Name of Card Holder *

First

Last

Company Name of Card Holder *

Credit Card Billing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Number Associated with Credit Card *

Email *

By submitting this form you agree that Holland 1916 will charge this credit card for materials/services purchased.

Credit Card Payment Form

By submitting this form you agree that Holland 1916 will charge this credit card for materials/services purchased.

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Kansas City, MO, USA