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db Video, LLC
[email protected]
Mailing: 242 W. Main Street #229 Hendersonville, TN 37075
Physical: 474 Woodycrest Avenue Nashville, TN 37210
Phone: (615) 319 – 8928
Fax: (615) 782 – 2041
ACCOUNT SETUP & CARD AUTHORIZATION FORM
Please complete and return the account information below. All information will remain confidential.
Company Name:
Company Street Address:
Company City, State, Zip:
Company Phone:
Contact Name:
Contact Email:
Accounting Email:
Tax Exempt:
No
Yes (Documentation Required)
Cardholder Name:
Billing Street Address:
Billing City, State, Zip:
Card Type:
Visa
MasterCard
Discover
AmEx
Card Number:
Card Expiration Date:
Card Verification Number:
I agree to allow db Video, LLC to use the above card/account as a condition of extending credit terms on
an open account or as a guarantee of insurance deductibles for claims that may arise.
All card charges will include an additional 4% processing fee.
Signed:
Date:
Check here to indicate:
Yes, Please charge my card for my order. (Estimate#/Job name:
No, Please do not charge my card. I will mail a check for my order.
)