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MOPED WORLDŽ
Copyright Š Moped WorldŽ
MOPED WORLDŽ
MOPED WORLDŽ
P.O. Box 27034
Greenville, SC 29616 USA
Name:_____________________________________

Shipping Address:____________________________

__________________________________________

City:______________________________________

State:__________________    Zip:______________

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 may call to verify order and charges before shipment. We check the validity of all credit cards. Remember to write down your bank's telephone number and sign this form before mailing 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

_________________________________________
Your Signature

Please Charge my
(Circle One)

Visa  Mastercard