Credit Card Authorization Form

(Please print this page, complete the information and fax it to
the number listed to the right. Your order will not be processed
until we receive this information.)

Ezra
807 E. 12TH STREET SUITE 129
Los Angeles, CA 90021
United States
Tel: 213-593-9066 • Fax: 213-593-9069
e-mail: candycouture72@yahoo.com

   

 

Company Name:    

Cardholder Information

Name (as stated on card):  
Billing Address:   Tel:  
    Fax:  
     
 
Credit Card Type: American Express
Visa
MasterCard
Discover Card
Credit Card #:  
CVV #:  
  The CVV is the 3-digit number located on the back of your card. For AMEX, the CVV is the 4-digit number on the front of the card.
 
Expiration Date:    
(i.e. 01/2012)  
 
Please check all boxes
I hereby authorize to process my order PO# _______________ and/or INV# _______________ with the above credit card for the amount of no more than _______________ (please write original order amount) plus Shipping & Handling fees.*
I agree that I will not initiate any dispute on this charge in the future, for the reason of "No Cardholder Authorization".
I will provide with copy of proof of identity and ownership of credit card upon request.

 

Cardholder Signature:   Date: