Credit Card - Agency Garment Packing

Credit Card / Bank Card Authorization Form

Company Name*

Name*

Billing Address*

City*

State*

Zip Code*

Phone Number*

E-mail*

Card Type*

Credit Card

Bank Card

Card Number*

Exp Date*

C.V.C # (Last 3 or 4 digits number on the back of the credit card)

I hereby affirm that I am the owner of the referenced credit card and that my name is listed on the front of the credit card.

I hereby authorize Agency Garment Packing to charge my credit card (listed above) in the amount of $ for payment and goods services

Keep Card on file for future payments

Print Name*

Date*

Signature*

To process your order, provide us a copy of your identification and a copy of your credit card (both front and back sides of the card).

Copy of Identification *

Copy of Card *