November 30, 1995
CREDIT CARD AUTHORIZATION REQUEST FORM.
Date: Sales agent (Bon Trade):
Customer No.(if available): Customer/Company name:
Requested by: Charge amount (US$):
I hereby authorize Bon Trade Intl. Corp. to debit my credit card account for the purchase of parts and services requested by me with reference to the order placed by me, my company, my principals and/or my representatives. The information contained in this request is current and correct to the best of my knowledge, and is confidential. I accept the terms and conditions set forth by the credit card company and the sales policies of
Bon Trade Intl. Corp.
Method of Payment
Visa MasterCard American Express Diners Carte Blanche
Credit Card No: Printed digits (3 on sign. strip or 4 on front of Amex):
Name of cardholder (as it appears on the card):
Year issued: Telephone# of card holder:
Expiration Date: Fax # of card holder:
Date of Birth of cardholder:
Credit card statement mailing address:
Copies of both sides of the credit card, and of the ID provided by the cardholder, must accompany this form!
To avoid delays please fill out completely.
Signature of cardholder.
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