Ship to alternate address form

Credit Card Use Authorization



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