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
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