Daytime Phone #: (______)_______-_____________
Home Phone #: (______)________-______________
Shipping Address must match the billing address. If it doesn't, call the 1-800 Customer Service number located on back of card and set up an "Alternate Shipping Address." Give them the Shipping Address above. Information is kept confidential. We will call to verify receipt of fax within 24 hours. We check the validity of all credit cards. Remember to write down your bank's telephone number and sign this form before faxing it in.
Account Number on Card
Expiration Date Name of Bank Issuing Card
Your name as it appears on Credit Card
1-800 Customer Service# on back of Card
Please Charge my: