Credit Authorization Form

www.tireXpresswarehouse.com

Name of Business


_______________________________________

Full name of credit card owner


_______________________________________


Last four digits of credit card used


_______________________________________


Address for credit card


_______________________________________


Address where shipment is going


_______________________________________


Number of units ( each tire is a unit )

_______________________________________


Price agreed on each unit


_______________________________________


Create a five digit pin ( note any 5 digits you will remember )


_______________________________________



Today's date


_______________________________________


Please print full name and sign


_______________________________________

Please fax this completed form to 607 432 0291