Kangaroo Inflatables Credit Card Authorization Form

Company Name ___________________________________

 

Contact Person ____________________________________

 

Company Address ________________________

 

City____________State _______Zip_____

 

Shipping Address _________________________

 

City_____________State _______Zip_____

 

Business Phone __________________________________

 

Fax Number ______________________________________

 

E-mail Address ____________________________________

 

Company Web Site _________________________________

 

I hereby Authorize Kangaroo Inflatables to Charge the

credit card listed below On Date _________ for the amount of

 

$___________ to start production on the unit(s) ordered.

For Invoice number __________

I understand production will not begin until the credit card is charged.

 

I here by authorize Kangaroo Inflatables to Within 48 hours

prior to shipment of the products ordered to charge the

 

Credit Card indicated below for the full remaining balance

amount of $___________

 

I _(Name)__________________________________have read

and accept Kangaroo Inflatables terms and conditions.

 

Check One

 

Visa ___ Master Card ___ American Express ___ Discover ___

 

Credit Card Information

 

Card # ____________________________

 

Card holder name ___________________________________

 

Expiration date Month ______Year _____

 

Code on back of Credit card _______________

 

Credit Card Billing Address ______________________

 

City___________State ____Zip________

 

Drivers License # _______________________

 

Authorization Signature: _________________________________

 

Print your First __________________ Last Name_________________

 

Date ________

 

If Shipping address and Billing address are not the same,

Please provide a copy of the credit card (front and back) and your driver license