www.FashionWholesaler.com

Tel: (562) 404-8557

Fax: (562) 404-0181

 

Credit Card Payment Authorization Form

 

Dear Customer:

 

In order to avoid any fraud charges. Please provide the following information. If your shipping address is different from the billing address that the credit card issuing bank has on file. Please fax it back (562) 404-0181 or E-mail the form with your authorized signature. We are not responsible for any delay due to the insufficient information and mis-match for address verification. We do appreciate your understanding and cooperation.

 

ORDER #____________

 

Name:                                                                                      Drivers License#                   

                                                                                                                                                               

Company :                                                                                EIN#                                    

Employee Identification Number

Card type (VISA, MC, AMEX , DISCOVER CARD  ):                                                      

 

Card Number:                                                                          Security#                              

**The 3-digit security number is printed on signature panel on the back of the card**

 

Card Expiration Date:                                       Card Holder’s Name:                                   

 

Credit Card Issuing Bank:                                                                                                        

 

Credit Card Issuing Bank Tel:                                                      Fax:                                   

 

Billing Address:                                                                                                                     

 

                                                                                                                                            

 

Shipping Address:                                                                                                                 

 

                                                                                                                                            

**If your shipping address is different from the billing address, please call the credit card company to add the shipping address as alternative address. It will protect the usage of the credit card.

 

I,                                               , authorize FashionWholesaler.com to charge my current and future purchases to the credit card provided above. I am also well acknowledged and agree to the store policies and return policies. Stated on www.FashionWholesaler.com and www.Gifts-Pontier.com. .

 

                                               

Authorization signature