close

Вход

Забыли?

вход по аккаунту

код для вставкиСкачать
CREDIT CARD AUTHORIZATION FORM
(Please complete and print this page and fax or email the copy to the information
listed to the right. Your order will not be processed until we receive this information.)
COMPANY NAME:
CARD HOLDER INFORMATION
Name (Exactly as on your card - writing this must be card holder):
ST&T (DBA Verona)
11808 Burke St
Santa Fe Springs, CA 90670
TEL: 213-765-3450
FAX: 213-765-3435
Email: [email protected]
Billing Address (Must be the exact):
Please place your credit card faced up here
for a copy ONLY if requested
TEL:
(SECTION A)
FAX
Credit Card Type (VISA, MASTER, AMEX, DISCOVER)
(SECTION B)
Credit Card #:
Expiration Date:
CVV#
I am agreeing to all of the following 1 - 4:
1. I hereby authorize Verona to process my order (see below) with the above credit card for the amount due.
2. I agree that I will not initiate any dispute on this charge in the future, for the reason of "No Cardholder Authorization"
with Verona.
3. I will provide Verona with copy of proof of identity and ownership of credit card upon request.
4. I authorize Verona to use this credit card for my future orders and store my credit card information for future
orders.
________________________________________
Cardholder Signature
__________________________________
Date
1/--страниц
Пожаловаться на содержимое документа