CREDIT CARD AUTHORIZATION


Please complete the following with your name and address as it appears on your credit card
statement.  It is important that this information is correct, as we verify all information with the credit card
company for your safety.

Cardholder’s Name   ______________________________
                                                        
Billing Address           ______________________________
                                                 
City      ____________________          State  ______      Zip   ____________
               
Telephone     _______________            Fax    ____________
                                
Purchase Order Number  ___________________________
          
Visa                 Mastercard                 Discover            American Express 

Credit Card Number       ____________________________     
                                                
Expiration Date              ______/______       

By signing below, I authorize ______________ to charge my credit card

   $   ____________  (not including shipping charges)


Cardholders signature  ___________________________          Date ____________
                                                        

                      
                                        For office use only

Amount Charged $:                                Invoice Number:                     Charged By:                     
Input Date:                                                 Sent By:                           Approved Date: