The Back Massager
24 Wellsley Lane
Coram NY 11727
Toll Free 1-877-765-MASSAGE
CREDIT CARD/FTC AUTHORIZATION FORM
1. Complete the form by printing legibly with a dark pen, all billing and shipment information in
the blanks below.
2. Sign with the credit card holder’s signature on the line indicated.
3. I have read and agreed to the terms of the Federal Trade Commission.
4. Include a copy of your drivers license
5. Please fax this form to 631-403-4520 signed and with the copy of your drivers license.
I _____________________________________ hereby authorize The Back Massager to charge
my credit card account in the amount of $___________________ 100% refundable deposit.
Type of card VISA MASTERCARD DISCOVER AMERICAN EXPRESS
Credit Card Number __________________________________________
Expiration Date:________________CVC Code (last 3 digits on the back of the card ______
Credit Card Billing Address:
Shipping Address if different
As the Credit Card holder, I hereby authorize receipt of merchandise at the shipping address
Cardholders Signature X_____________________________________________________
Your completion of this authorization form helps us to protect you, our valued customers from
Credit Card fraud. All information entered on this form will be kept strictly confidential by The
Upon completion fax all documents to 631-403-4520.