CREDIT CARD AUTHORIZATION FORM

COMPLETE THIS FORM AND FAX TO
805-578-8762

BILLING ADDRESS

SHIPPING ADDRESS
Name: Name:
Address: Address:
   
City: City:
State/Province: State/Province:
Zip Code: Zip Code:
Country: Country:
Home Phone: Home Phone:
Work Phone: Work Phone:

CREDIT CARD INFORMATION

SHIPPING OPTION
Card Type: Visa [   ]      MasterCard [   ]      Discover [   ] UPS Next Day [   ]  UPS 2nd Day Air [   ]  UPS Canada [   ]
Card Number: U.S. Priority Mail [   ]  FedEx Overnight [   ]  FedEx 2nd Day  [   ]
Expiration Date: Month [                        ]   Year [            ]
  Customer is responsible for all freight charges and is billed in addition to parts costs.

Authorized Signature

Date Signed:

Place Credit Card here with tape information side up.

 

Photocopy after this form after all information is filled out, signed and dated.

 

Place valid Driver’s License here with tape with your photo side up.

 

Credit Card and Driver’s License must have matching name. The billing address must match the Driver’s License address.

 

After all information is filled out, Credit Card and Driver’s License is affixed as designated and all signatures are applied then photocopy completed form and fax to 805-578-8762. 

Safari4x4 reserves the right to refuse business to anyone.
 

For shipments by truck freight, customer acknowledges that parts must be pre-paid, and that truck freight will come C.O.D. collect for freight charges, and that customer is responsible for all fees associated with truck freight.

 
Sign Here: