Ship to alternate address form
| Credit Card Use Authorization | |
Date:_______________________ | |
To: NOVA COMPUTERS | |
From: ____________________________________ | |
Dear Merchant: | |
| I am in receipt of the invoice order and acknowledge the description of the merchandise/services. | |
| I recognize and confirm the total charge in the amount of | |
_______________________________________________ US Dollars | |
I hereby authorize use of my credit card # __________________________________________ | |
| American Express __ Mastercard __ Visa __ Expr Date: ___/____ Security Code_____ | |
| For payment of said merchandise/services. | |
| I agree to pay the amount show above as it appears on invoice order #_________________ | |
| Card Holder Name (Print) ___________________________ | |
Card Holder Signature: ______________________________ | |
| Billing Address: ________________________________________________________________ | |
| Phone #: ______________________________________________________________________ | |
| Shipping Address: ______________________________________________________________ | |
Driver License #:____________________________ State:____________ | |
| Please fill out the form, Sign and obtain notary public certification (at your bank or similar Public Notarizer) together with undoctored Photocopies of card holder driver licence and credit card, and fax to 1-206-600-4293 Attn: Sales Department | |
