AUTHORIZATION TO CHARGE CREDIT CARD

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					            AUTHORIZATION TO CHARGE CREDIT CARD

I,______________________________________AUTHORIZE RPM DIESEL TO CHARGE MY
CREDIT CARD NUMBER,_____________________________________EXP. DATE:___/____
(Please provide a copy of the front and back of the card with this fax.) CVC #_______
(3 or 4 digit security code located on front or back of card)

FOR THE AMOUNT OF $___________________(U.S. DOLLARS), FOR THE PURCHASE OF:
_______________________________________________________________________________
CUST. NAME AS IT APPEARS ON CARD:___________________________________________
BILLING ADDRESS OF CARD:____________________________________________________
TELEPHONE NUMBER:__________________________________________________________
SALESPERSON NAME:___________________________________________________________

Is your shipping address different from your billing address?
To protect the security of your credit card: if your order is shipped to an address that is not the billing
address on your credit card, please make sure the shipping address is on file with your credit card
company.

Simply call the 800 number on the back of your credit card and ask the agent to add the shipping address
to the notes on your account. This will not change the billing address of your card. Doing this in advance
will speed up the processing of your order. Your order will not be shipped until we verify the address.

We will verify the address with your credit card company. If we cannot verify the address with your
credit card company, we will contact you to either ship to your verified billing address or use an
alternate payment method, such money order or wire transfer.

Are you an international customer paying by credit card?
We have to verify your information with the credit card company. Depending on the country and the
credit card company, they may not verify the information for us. If we cannot verify your information,
we will contact you for an alternate form of payment, such as a wire transfer or international money
order.

Are you shipping to a PO Box?
If you have a PO box address, please select US Mail for the shipping method. UPS/FedEx will not
deliver to PO Boxes.

I understand, that by using my credit card to purchase and/or expedite shipment of any parts or
equipment, I have waived my right with any credit card carrier to stop payment or rescind any
purchases or orders, until said purchase of parts or equipment have been returned to RPM Diesel
Engine Co., Inc. and or any of their assignees in satisfactory condition, then a credit memo will be
generated less any applicable restocking charges; freight and handling costs, then, and not until
then, will RPM Diesel Engine Co., Inc. post a credit memo to the corresponding charge card used
for this purchase.

__________________________________________ _______________________________________
Print Name Please                                    Authorized Signature

                        2555 W State Road 84, Fort Lauderdale, Florida 33312
                BROWARD: 954-587-1620 DADE: 305-947-2607 FAX: 954-583-7939
                                         1-800-660-6304
                 Email: Debbieyb@RpmDiesel.com      Web Site: WWW.RpmDiesel.com

				
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posted:9/28/2011
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