The Better Choice

DollarItem.com

Credit Card Authorization

CONCORD

DollarItem.com                                 The Better Choice                                       Import

 

3151 Fruitland Ave. Vernon California, 90058

Tel: (323) CON-CORD  Or  (323) 588-8888 Fax: (323) 588-2288

 

Credit Card Autorization Form

Attention:______________________________________________ Fax #: (______) _________  __________

 

Account  #: _____________ Invoice  #: ______________ Amount$: __________Date: _____________

 

I, ___________________________hereby authorize Concord Import 

 

to charge my credit card for purchasing general merchandise or applying towards my account.

 

Company name:  ________________________________________________________

 

   Card Holder’s : Last: _______________________First: ________________________

 

Card Holder Mailing Address:

 

Address: _________________________________________________________________

 

      CITY: _________________________________STATE:___________ ZIP: __________

 

Card Holder Phone #: (___________)  _________________________________________

 

Driver license #: ________________________EXP.: ____/ ____/ ____ DOB:  ____/ ____/ _________

 

Name Of card :      VISA [  ]      M/C [  ]      AMER.EXP [  ]      DISCOVER[  ]

 

Credite Card Number #:  ___________________________________________________

 

             Expiration Date: _____/  ____/  ________________Security Code:____________

 

             Total Amount : $ ___________________________________________________

 

 Card holder signiture : X _________________________________________________

 

 Print and sign and FAX  to :  (323) 588-2288 or email to : info@dollaritem.com

Back