C.S. Associates Inc. D.B.A Jante Shoes Credit Card Authorization Form I, ______________________________________, hereby authorize C.S. Associates Inc., dba Jante Shoes, to charge my credit card account in the amount not to exceed: $________________ ( ) Visa ( ) MasterCard ( ) American Express ( ) JCB Credit Card Number: ____________________________________________________________ Expiration Date: ______ /_______ CVC: ___________ Credit Card Billing Address: Street: ________________________________________________________________________ City: _____________________________________________ State: ____________________ Zip Code: _________ - __________________ Country: (if not U.S.) ____________________ Telephone: ( ) ________ - __________ Requested Shipping Address: Street: ________________________________________________________________________ City: __________________________________________ State: ________________________ Zip Code: _________-___________ Country: (if not U.S.) ____________________ Telephone: ( ) ________-__________ As the credit card holder, I hereby authorize the goods and services at the shipping address above. _________________________________________________________ _________/______/________ Cardholder’s Signature Date As the credit card holder, I also authorize C.S. Associates Inc., dba Jante Shoes, to charge my credit card for future purchases verbally approved by me. Authorization Valid Until: __________/____________ Initials Here: ____________ Your completion of this authorization form helps us protect you, our valued customers, from credit card fraud. C.S. Associates Inc., dba Jante Shoes, will keep all information entered on this form strictly confidential.
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