CREDIT CARD AUTHORIZATION FORM

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I, ___________________________, hereby authorize Firefly Propane, LLC to charge my credit card account
for all goods
and services purchased by me. I also authorize Firefly Propane,
LLC to retain my credit card information for future purchases
until I notify Firefly Propane, LLC in writing that I no longer wish to make purchases on my credit card.

Credit Card Billing Address:
Street: _________________________________________
City: ______________________
State: ____________
Zip Code: ______________
Telephone: (______) ______-____________
Home Address
(if different from billing address):
Street: _________________________________________
City: ______________________
State: ____________
Zip Code: ______________
Telephone: (______) ______-____________
Please check one:
( ) VISA ( ) MASTERCARD ( ) AMERICAN EXPRESS
Credit Card Number: _________________________
Expiration Date: _______/______
VID Code: ______________ (last three digits on back
of card by signature or four digits on front of card above account number for AMEX)

_________________________________________________
Cardholder signature Date
Your completion of this authorization form helps us to protect you, our valued customer, from credit card fraud. Firefly Propane, LLC
will keep all information provided on this form strictly confidential.