CREDIT CARD AUTHORIZATION FORM

 

Date:

Name of Credit Card Holder: 

Company Name: 

Phone: 

Fax:

Email:

Card Billing Address: 

 

Shipping Address:

Visa______MasterCard______American Express______Discover______

Credit Card #:

Expiration date: 

Products to Purchase:

 

 

 

 

In order to avoid fraudulent transaction and unauthorized use of credit card, please verify the information listed above and to authorize this transaction by signing below. Thank you.

Authorized by:

Date:

(Credit Card Holder Signature)

   

Please fax this Form back to Atlantic ComputerTech, Inc. at (718) 232-3981