Credit Card Authorization Form
(Please print this page, complete the information and fax it to the
number listed to the right. Your order will not be processed until we
receive this information.)



,
Tel:
Fax:

Company Name:_____________________________
Cardholder Information

Name (as stated on card): _______________________________________________________
Billing Address: ______________________ Tel: _________________________________
  ______________________ Fax: _________________________________
  ______________________    
Credit Card Type:

Expiration Date: _______________
(i.e. 01/2015)

Credit Card #: ____________________________

CVV #: __________
(The CVV is the 3 digit number located on the back of your card)
Note: In the case of AMEX the CVV is the 4 digit number on the front of the card.

Please check all boxes
I hereby authorize to process my order PO# _______________ and/or INV# _______________ with the above credit card for the amount of no more than _______________ (please write original order amount) plus Shipping & Handling fees.*

I agree that I will not initiate any dispute on this charge in the future, for the reason of "No Cardholder Authorization".

I will provide with copy of proof of identity and ownership of credit card upon request.

______________________________
Cardholder signature

______________________________
Date

* Rates may vary depending on the carrier of choice.