🔒 Secure Form

This form uses encryption to protect your sensitive information. Your full card number and CVV are NEVER stored or transmitted. Only masked information is sent for verification purposes.

Materiales Para Construccion Triple AAA Inc.

6521 Paredes Line Rd.

Brownsville, Texas 78526 USA

Tel. (956)504-9064 & Fax (956)5447761

CREDIT CARD AUTHORIZATION FORM

For use by Materiales Para Construccion Triple AAA, Inc.

A 2% Convenience Fee on all Credit Card Transaction

Privacy & Security: We take the protection of your personal and financial information seriously. This authorization form securely transmits your contact information and authorization to charge your card. For security, card details are collected via phone call and entered directly into our secure Clover payment terminal. Your data is never stored or transmitted via email.

🔒 SECURE PAYMENT PROCESSING VIA DEJAVOO API

Your payment is processed in real-time through our secure Dejavoo payment system:

Card data transmitted directly to PCI-compliant Dejavoo servers
Instant payment authorization (15-30 seconds)
Automatic receipt sent to your email
Same secure system as in-store payments

Credit Card Information

Card Holder's Name: * (exactly as it appears in the card)

Credit Card Number: *

Expiration Date: *

CVV#: *

Credit Card Zip Code: *

Type of Card: *

Visa Master Card American Express Discover

Billing Information

Send Receipt To: (email) *

Card Holder's Billing Address: *

City, State, Zip: *

Card Holder's Phone #: *

Authorization

Invoice # *

Enter invoice number to auto-load amount

Amount to Charge: * (USD)

Amount will be automatically loaded

I hereby authorize Materiales Para Construccion Triple AAA, Inc. to charge my credit card listed above in the amount of $0.00 to pay for goods purchased.

Signature

Please sign in the box below

Signature

Signature required

Printed Name: *

Upload Photo ID *

Required: Please upload clear photos of your valid government-issued photo ID (driver's license, passport, or state ID).

ID Front Photo: *

Front side of your ID (JPG, PNG, max 10MB)

ID Back Photo: (optional)

Back side of your ID (JPG, PNG, max 10MB)

🔐 Secure Automatic Submission

When you submit this form, only the following information will be sent to Materiales Triple AAA:

• Your name, email, phone, and billing address
• Card type and last 4 digits only (e.g., Visa ****1234)
• Charge amount and invoice number
• Your signature and ID photos

✓ Your full card number is NEVER transmitted
✓ Your CVV is NEVER transmitted
✓ All data is encrypted during transmission

What happens next?

Your form and ID photos will be automatically sent to Materiales Triple AAA. You'll also download a PDF copy for your records.

Materiales Para Construccion Triple AAA Inc.

CREDIT CARD AUTHORIZATION FORM

Credit Card Information

Billing Information

Authorization

Signature

Upload Photo ID *

✅ Payment Successful!