Purchase Authorization Form

fax to 1-888-270-1815
Alternate Fax Number (707) 581-1701

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6 DIGIT ORDER NUMBER

 

 

 

 

 

 

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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
PLEASE SHIP MY ORDER TO:
______________________________________________
Name

______________________________________________
Street Address

______________________________________________
City                              State                        Zip Code

__________________________________
Telephone

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