Credit Card Payment Authorization Form

Instructions: Fax the completed and signed form to 360-653-2856.

Check one:    Visa     MasterCard    American Express     Discover

 

Credit Card #:    _________________________________

 

Exp. Date ___________________

 

Name as appears on card:     _________________________________

 

Company name on card:   #:    _________________________________

(if applicable)

Credit Card billing address:  _________________________________

 

City:  _____________________    State: ____      Zip: __________

 

Telephone Number: _________________________________

 

Fax Number:  _________________________________

 

Please ship the products to:

 

Name:     _________________________________

 

shipping address:  _________________________________

 

City:  _____________________    State: ____      Zip: __________

 

Telephone Number: _________________________________

 

This authority is for a one time charge according to the information provided below.

 

Invoice # or Order  #:  _______

 

Payment Amount:   $ ________

 

I authorize ForeverWed, Inc. to charge my credit card for payment  of their products and/or services and ship the products to the addressee above.   If Foreverwed, Inc. is unable to process my payment I will be responsible for an alternate payment arrangement and any resulting processing fees. By signing this authorization, I acknowledge that I have read and agree to all of the above  Information and warrant all information given is true.

 

Signature of Card Holder:  _________________________________

 

Printed Name of Card Holder:  _________________________________

 

Date:  _________________________________