Credit Card

Credit Card / Bank Card Authorization Form

Name

Billing Addres

City

State

Zip Code

Phone Number

E-mail

Card Type

Credit Card

Bank Card

Name

Exp Date

C.V.C # (Last 3 or 4 digits number on the back of the credit card)

I hereby affirm that i am the owner of the referenced credit card and that my name is listed on the front of the credit card.

I hereby authorize by Agency Garment Packing to charge my credit card (listed above) in the amount of $ for payment of goods and services.

Keep Card on file for future payments.

Print Name

Date

Signature

To process your order, provide us a copy of your identification and a copy of you credit card (Both front and back sides of the card).