Check Card Type
VisaMasterCardDiscoverAmerican Express
CardholderName(asshownoncard):
CardNumber: Billing Address affiliated to credit card. ExpirationDate Phone:
,authoriz
tochargemycreditcardaboveforagreeduponpurchases.Iunderstandthatmyinformationwillbesavedtofileforfuturetransactionsonmyaccount.
29Company Name: STRIKER PHARMACY, LLC
Billing Address: 1330 Pin Oak Rd. Katy, Texas 77494
Account number: 672298905
Routing number:021000021A
FormBy signing this Credit Card Authorization Form, I agree to be financially responsible for the payment of all prescription and other medications, supplies, and pharmacy service fees including, but not limited to, delivery and administrative fees provided to the Customer. I agree to provide Striker Pharmacy with any and all current information regarding prescription insurance coverage or medical assistance programs under which the Customer is eligible. If the Customer’s insurance company or medical assistance program does not pay the entire balance of an item, the balance due will be charged to this account. I agree to allow Striker Pharmacy to retain a copy of my credit card on file. There will be a 3% credit card fee.
