Unverified Paypal Account Credit card Authorization

Unverified Paypal Account 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 paypal to charge 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 #_________________(please enter the last 4 digits of the order number)
and will withold any unreasonable dispute UNLESS I return the original merchandise un-used back to the intended seller.


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) and fax to 1-206-600-4293 Attn: Sales Department