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The document is a credit card authorization form for a customer to pay $300.80 to Pager Part Mart, Inc. for an order or invoice. It lists the customer's credit card number, expiration date, and security codes. It notes that the total includes a 2-3% credit card processing fee. The customer agrees not to dispute the credit card charge and provides their name, billing address, phone numbers, and a copy of their driver's license and credit card for verification.

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Jim Bean
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2K views1 page

Credit

The document is a credit card authorization form for a customer to pay $300.80 to Pager Part Mart, Inc. for an order or invoice. It lists the customer's credit card number, expiration date, and security codes. It notes that the total includes a 2-3% credit card processing fee. The customer agrees not to dispute the credit card charge and provides their name, billing address, phone numbers, and a copy of their driver's license and credit card for verification.

Uploaded by

Jim Bean
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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The Preferred Prepaid

A division of: Pager Part Mart, Inc.


56 Tesla, Irvine, CA, 92618
Tel: (877) 355-4287
Fax: (949) 682-1891

I, ~~Icb L-LJj<lf. authorized card holder, authorize Pager Part


Mart, Inc dba CeliGateUSA to charge my VISA __ M/C__ AMEX ~dit
card number ]7!:) I 711 410 ~ '11 r; g expiration date 7- ~d---,J<-( (~ lo~
the amount of $ :loa <' B0 for order/invoice # _
4 digit security code for Amex in front of the card <DS I!!)
or 3 Digit 'security code for VISA & MC in the back of the card _

The total dollar amount includes 2% (3% for AMEX users) credit card charge.
I will waive any dispute on this credit card charge for whatever reason.

»0 NtlYh<-- ItVl?W;(~ fcS:5 fr<f4.fd S'er{/'( {4rd


Card holder name ( int as it appears on the card)

Bill to address (include City, ST, Zip)

G-d---JLf
~~ Date

~cOe>-1'5'1-055 1
800 # (on back of card)

/2Aj-f?-I--/osP
Home phone #

Please fax back to us at 949-682-1891 with a copy of your driver's license and
credit card (front & back) with this authorization.
Thank you for your business.

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