Credit Card Authorization Form doc - DOC by longze569

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									                         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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