<p> GOLDEN STATE FIRE PROTECTION, INC. 15535 Arrow Route Fontana, CA 92335 Mailing: P.O. Box 3697 Fontana, CA 92334-3697 (909) 356-5644 Fax: (909) 356-5649 Automatic Sprinklers & Fire Protection Systems ~ Lic. No. 350225</p><p>CREDIT CARD AUTHORIZATION</p><p>DATE: </p><p>NAME AS IT APPEARS ON CREDIT CARD </p><p>BILLING ADDRESS FOR CREDIT CARD </p><p>AUTHORIZED SIGNER NAME </p><p>CREDIT CARD TYPE  VISA  MASTERCARD</p><p>ACCOUNT NUMBER EXPIRATION MM YR </p><p>SECURITY CODE (Required) (LOCATED ON BACK OF CARD)</p><p>DESCRIPTION OF ITEMS ORDERED:</p><p>Inv. # DW# Contract#GSFP</p><p>AUTHORIZED SIGNATURE: </p><p>AMOUNT CHARGED: </p><p>YOUR CREDIT CARD STATEMENT WILL SHOW A CHARGE BY: GOLDEN STATE FIRE PROTECTION, INC.</p><p>THANK YOU FOR YOUR BUSINESS! Email this form to: [email protected]</p>