Credit Card Authorization Form

Published on June 2016 | Categories: Documents | Downloads: 85 | Comments: 0 | Views: 547
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Credit card Authorization Form
(Please print this page, complete the information and fax it to the number listed to the right, Your will not be processed until we receive this information.)

MOA COLLECTION (MOAUS.COM)
1458 S. SAN PEDRO ST. #L49 LOS ANGELES CA 90015 TEL 213-746-6543 FAX 213-746-4563 [email protected] Company Name :

Cardholder Information
Name : (as stated on card) Billing Address: Tel: Fax:

Credit Card Type: American Express Visa MasterCard Discover Card
the back of your card) number on the front

Credit Card #

CVV #
(The CVV is the 3digit number located on Note: In the case of AMEX the CVV is the 4 digit

Expiration Date:

of the card.

Please check all boxes I hereby authorize Pave Handbags to process my order PO# and/or INV# with the above credit card for the amount of no more than $

I agree that i will not initiate any dispute on this charge in the future, for the reason of " No Cardholder Authorization". *Rates may vary depending on the

Cardholder Signature
choice.

Date

carrier of

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