AUTHORIZATION FOR CREDIT CARD PAYMENT - Auto Parts …

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AUTHORIZATION FOR CREDIT CARD PAYMENT

SALESPERSON: CUSTOMER/COMPANY NAME: NAME ON CREDIT CARD: CREDIT CARD #:

SECURITY CODE:

QUOTE #: ______________________ PO#:

EXP DATE:

MC VISA DIS

(AMEX not accepted)

AMT $:

PART(S) REQUESTED

PART RECIPIENT VIN: CARD BILLING ADDRESS: CITY, STATE, ZIP CODE: TELEPHONE NO:

SHIP-TO ADDRESS:

(if different from billing)

CITY, STATE, ZIP CODE:

PRINTED NAME: SIGNATURE:

DATE:

SEND A PHOTO COPY OF THE CARD HOLDER'S PICTURE ID AND CREDIT CARD

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