5455 de Gapsé, Suite 903E Montreal, Quebec. Canada, H2T 3B3
514-‐885-‐4300
VISA/ MASTER CARD AUTHORIZATION FORM
Dear Sir/Madam, In order to process your purchase with our company, we require the following information: Name of your Company____________________________________________________ Authorized credit card_______________________VISA____________________MASTER Card number:_____________________________________________________________ Expiry date:__________________ Security code:_________________ Cardholder Name:_________________________________________________________ BILLING ADDRESS: Store name: _______ Street Address: City/Town: Tel:( ) Contact for Accounts Payable:
P.O.BOX :
Prov/State: Postal Code: Fax: ( ) E-‐mail _______ years in business _______
SHIPPING ADDRESS: (IF DIFFERENT THAN ABOVE) Store name: ______ Street address: City/Town:
Prov/State:
P.O. Box: _______Post.Code/Zip:
______
_____________ ______ Tel:( )
•
For Custom Name Dropped or Embroidered orders, we will take ½ deposit in advance.
•
We will require a “photocopy of the actual front and back of the credit card described above” for our records
Disclaimer: I hereby authorize “Hip and Bone” to accept orders from our business, charge the cost of the orders to my credit card noted above, and to ship the merchandise as requested. By signing the document, I am accepting all the responsibility for these transactions to ensure full payment to the merchant. I will inform you immediately if use of this card is no longer valid. Signature:________________________________________ Date:___________________ FED ID # (IRS #/EIN #)______________________________ (FOR U.S. CUSTOMERS ONLY) Thank you for your cooperation.