CREDIT CARD
AUTHORIZATION FORM
In lieu of my credit card
imprint, I __________________________________, hereby authorize Hi-Performa=
nce
Designs, Inc., or their representative to charge my Credit Card for the amo=
unt
shown below. By signing below=
, I
acknowledge the charges described below.&n=
bsp;
CARD HOLDER’S NAME:
_______________________________________
CARD TYPE (circle): VISA MASTERCARD &=
nbsp; AMERICAN
EXPRESS
CARD NUMBER: ____________________________CCV
#____________EXP_____/______/________
TOTAL AMOUNT AUTHORIZED TO CHARGE TO ABOVE C=
ARD:
$________________________ FOR THE
PURCHASE OF: __________________________________
=
CREDIT
CARD BILLING AND SHIPPING ADDRESS:
=
=
_____________________________________________
=
=
_____________________________________________
=
=
_____________________________________________
HOME PHONE #:
_________________________________ &nbs=
p; FAX
# _____________________________
CARD HOLDER SIGNATURE:
__________________________________DATE:________
PLEASE COMPLE=
TE
THIS FORM, SIGN, AND FAX BACK TO 813/707-9893 INCLUDE A COPY OF YOUR CREDIT
CARD (BACK AND FRONT) AND A COPY OF YOUR PASSPORT OR DRIVER’S LICENSE
(BACK AND FRONT).