Purchase Authorization Form
fax to
(707) 581-1701
6 DIGIT ORDER NUMBER
PLEASE PROVIDE THE FOLLOWING INFORMATION:
1. Please print this page and fill in your order number in the box on the left.
2. Photocopy and attach:
A. Credit Card - Front Side
B. Credit Card- Back Side
C. Driver's License, State or Military ID for verification
3. Fill in the below information completely and sign & date on the bottom line.
4. Fax this form & items from 2A, 2B & 2C listed above.
___________________________________
Credit Card Number (Visa / Mastercard or Discover)
___________
Expiration Date
____________________
Credit Card Bank Name & Phone
____________________________________
Driver's License, State or Military ID Number
_____________________________________
Cardholder's Name - as it appears on credit card
CREDIT
CARD BILLING ADDRESS:
Address where monthly
credit card statement is received
__________________________________________
Billing Address
____________________
CVV Number - Last 3 digits on signature area (back of card)
__________________________________________
City State Zip Code
___________________
Home Telephone
___________________
Business / Other Phone
_________________
Fax Number
_______________________
Email Address
|
I, ____________________________ authorize On the World Wide Web to charge my credit card
Card Holder's Name
the amount of $______________ and ship the order to the address listed above. I also authorize them to call my bank to verify the above information.
______________________________________
Signature of Credit Card Holder
___________________________
Date
PLEASE BE SURE TO INCLUDE COPIES of Credit Card (Front & Back) and Drivers
License
Forms without these items will not be processed