Credit Card Authorization

Credit Card Authorization Form
(to be send by fax)

You can print out the form below as a blank form, then fill it out by hand and fax it to us, or you can fill out this form on your screen and then print it and fax it to us. It is up to you. Both ways, are the safest ways to send your personal and credit card information to us, or to any other trusted party.

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

Cardholder's First & Last Name:

Billing Address:

City:

State:

Country:

Purchase Order Number:

Credit Card Number:

Expiration Date:

Business Card:

Personal Card:

By signing below, I authorize ExclusiveWholesaler.com to charge my credit card

plus applicable shipping charges.

Cardholder's Signature

Date:

Security code:

Type of card:

Postcode: