Credit Card Authorization Form
Customer Name: __________________________________________
Name of Cardholder:___________________________________________________________(as it appears on the card)
Billing Address: _______________________________________________________________________________
City, St, Zip Code:_________________________________________________________
Shipping Address (if different from above)_____________________________________________________
City, St, Zip Code_________________________________________________________
Visa_____Master Card_____Amex_____Discover _____
Credit Card Number:_____________________________________ Exp. Date:_____________
CSC Number: _________ (found on the front of Amex and on the back of Visa and MasterCard)
Customer Service Phone Number from back of credit card:__________________________
Product(s) to be purchased: Handbags, wallets, home décor, footwear, jewelry, accessories
Purchase Total :_____________( please note you will also be liable for shipping charges and taxes if applicable)
_____(initials) I hereby authorize Simply eGalleria to charge my purchase to the above credit card for the account listed above. I certify that I am the authorized cardholder of record and that I have full authority to make purchases on behalf of the account listed above. I understand that at time items may be back ordered. I recognize that Simply eGalleria will issue immediate credit to the above listed credit card in the event my card has b.een charged for items that has become out of stock or back ordered.
_____(initials) Unless other arrangements have been made to the contrary, I hereby authorize Simply eGalleria to ship and charge the above credit card for back ordered items as they become available.
Signature: _________________________________________________________ Date: _______________________
Please provide a copy of the back of the credit card showing your signature and CSC.
Pease fax to 972-294-3341 or email completed form to email@example.com