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: |
__________________________________________ 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 |
||||||||
|