Credit Card Authorization

db Video, LLC 632B West Iris Dr. Nashville, TN 37204
(M)615.319.8928 | (O)615.782.2002 | (F)615.782.2041 |

Company Name:

Contact Name:   

Contact Email:   

Cardholder Name:   

Billing Street Address:   

Billing City:   

Billing State:   

Billing Zip:   

Card Type:   
Card Number:  
Card Expiration date:  
Card Verification #:  


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. 

Yes, please charge my card for my order. (Estimate #/Job name):  


Leave this empty:

Signature Certificate
Document name: Credit Card Authorization
Unique Document ID: 4d7f01782152a482f0535aa0370877dcb5ecc30e
Timestamp Audit
2016-10-12 00:00:42 CDTCredit Card Authorization Uploaded by Doug Bates - IP