Customer / Company Name*

Invoice / Reference Number*

Payment Amount (CAD)*

American Express is our preferred card, but also accept Visa and Mastercard.

Numbers Only. No spaces, dashes or any other characters.

Expiry Date*

Month 01 02 03 04 05 06 07 08 09 10 11 12    Year 25 26 27 28 29 30 31 32 33 34 35

CVC*

Payment Authorization I authorize Pothier Enterprises Ltd. to charge my payment method provided above for all agreed upon purchases. I understand that my information will be saved on file for future transactions on my account.

I have read and agree to the payment authorization terms above.*

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