Payments CUSTOMER INFORMATION Full Name (as shown in your card) Company Name Comments Billing Address 1 Billing Address 2 State City ZIP Phone Email CREDIT CARD INFORMATION Card Number Expire Date CVV Photo ID Upload Front of the Credit Card Upload Back of the Credit Card Disclaimer for Use of Credit Card Form By using this credit card form, you agree to the following terms and conditions: Accuracy of Information: You confirm that all the information provided in this form is accurate and truthful to the best of your knowledge. Legal Consequences of Fraud: Submitting fraudulent or misleading information may result in legal consequences, including but not limited to prosecution under federal law. In accordance with 18 U.S. Code § 1028, anyone who knowingly provides false information or attempts to commit fraud may face penalties including fines and imprisonment. Liability Waiver: BRS Roofing Supply is not responsible for any misrepresentation, fraud, or theft committed by users of this form. Users are solely responsible for the accuracy and legitimacy of the information they submit. Data Protection: By submitting this form, you consent to the use of the provided data for the purpose of completing your transaction. Your data will be handled in compliance with applicable privacy laws. Use of Services: The use of this form is intended only for authorized users. Any unauthorized or fraudulent use will be subject to prosecution under applicable laws. Affidavit of Truthfulness By submitting this form, I hereby declare under penalty of perjury under the laws of the United States of America that the information provided is true, accurate, and not intended to defraud. I understand that submitting false or fraudulent information is a violation of 18 U.S. Code § 1028 (Fraud and related activity in connection with identification documents, authentication features, and information) and may result in severe penalties, including fines and imprisonment. By clicking here you will be accepting our Privacy Policies, Cookies and Legal Warning I confirm that the following information is accurate and you are willing participant in BRS Roofing Supply, LLC charging the following credit card, debit card. In addition you acknowledge that not discount will be offered when paying via credit card or debit card. I authorized BRS Roofing Supply LLC to charge the agreed amount listed above to my credit card provided herein. I agree that I will pay fir this purchase in accordance with the issuing bank cardholder agreement. SUBMIT Form and authorization to apply download pdf Authorization download pdf Application