New Account Application Form

1. Company information

How did you find us?

2. Billing/Accounting Information

3. Shipping information

Credit Card Authorization Form

Please sign and complete this form to authorize ALAMBIKA to make a debit to your credit card listed below..

By signing this form you gives us permission to debit your credit card account for all invoices rendered.

IMPORTANT: If at any given date this information changes, please contact our office immediately to update your account information. It is our company policy that a valid credit card must be on file at all times. This also applies to all types of accounts, including NET 30.

(full name)
authorize ALAMBIKA to charge my credit card.

Account Type

(digits in the back of card)

I authorize ALAMBIKA to charge the credit indicated in this authorization form according to the terms outlined above, I certify that I am an authorized user of this credit card 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.


Date: 07/08/2020
PCI Compliant