Lafferty Secure Payments

Secure Payment Authorization Form

Please complete this form if you would like Lafferty Equipment Manufacturing, LLC to charge your credit card for an order. The use of this form is optional and for your convenience. Form results will be submitted and stored in an encrypted format until your order is processed.

Important: Please provide the address your credit card statement goes to NOT your shipping address.

Company Name: *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Phone Number *

Country *

Email Address *

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

CVV Number *

One Time Payment Authorization *

I authorize Lafferty Equipment Manufacturing, LLC to charge the credit card indicated in this authorization form. This payment authorization is for a pending order and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

Payment For *

Order Number 🛈

Invoice Number 🛈

Payment Amount 🛈

Terms and Conditions