Credit Card Authorization Form

Credit Card Authorization Form
®
For security purposes return this form to only these faxes:
Prepay Accounts: 714-765-0447
CUSTOMER NAME OR COMPANY
CONTACT NAME
CREDIT CARD#
Credit Accounts: 972-775-9196
CUSTOMER#
TELEPHONE#
EMAIL
CVV Code
CARD TYPE
VISA
ISSUING BANK
M/C
AMEX
EXPIRATION DATE:
/
MONTH
FULL NAME AS IT APPEARS ON CARD
DISCOVER
DISCOVER NOT
AVAILABLE ON WEB
YEAR
PLEASE CHECK ONE OF THE OPTIONS. IF NOT CHECKED,
WE WILL ASSUME ONE TIME USE ONLY.
KEEP ON FILE.
ONE TIME USE.
CREDIT CARD BILLING ADDRESS
CITY
STATE
ZIP
AUTHORIZED USERS OF THIS CARD
AMOUNT TO CHARGE TODAY
I understand that I am obligated to notify Alstyle Apparel/A&G, Inc. if there are any changes in authorized users. I further understand and agree
that my credit card account will be charged in the event the card is used by former authorized users, unless I notify Alstyle Apparel/A&G, Inc. in
writing, of changes in authorized users. My signature is my personal guarantee that I am soley responsible for payment of each transaction. I
understand that I will reference the last four digits of this credit card number on every purchase order. If it is not done it could cause a delay in
my shipment. I am responsible for providing Alstyle Apparel/A&G, Inc. with a new form prior to the expiration date of this credit card.
This form will be valid up to expiration date of this credit card. We require a new form upon reaching the expiration date of this credit card.
A signed Purchase Order containing the last four digits of the credit card number to be charged is required.
CARDHOLDER SIGNATURE
TELEPHONE#
FAX#
DATE
For office use only
Credit Card Verified by_______________________________________________________________ Date ____________________________
Rev 1/14
Alstyle Apparel