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Simply eGalleria


Credit Card Authorization Form


Customer Name:     __________________________________________

Name of Cardholder:___________________________________________________________(as it appears on the card)

Billing Address:  _______________________________________________________________________________

City, St,   Zip Code:_________________________________________________________

Telephone #:_______________________________________

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)

Email Address:___________________________________________________________________________


_____(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.


Printed Name:______________________________________________________

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