CREDIT CARD AUTHORIZATION

Customer Information

Contact Name:

Company Name:

Telephone:

Address:

Country:

Credit Card Account

Account Type:

VISA MASTERCARD DISCOVERY AMEX

Card Number:

Expiration Date:

Security Code:

Cardholder Name:

Billing Address:

Country:

Authorization

I authorize Ventiques to debit the credit card account provided above for the purchase of products by the above Customer. I also understand that this authorization will remain valid and continue until I cancel such authorization in writing.

Authorized Signature:

Date:

Please fill out and
send completed form via:

Mail:
301 34th Ave. S
Waite Park, MN 56387

Email:
nick@ventiques.triggerdev.com

Any information sent via E-Mail is not secure and is being transmitted at sender’s own risk.

It is the Customer’s responsibility to inform Ventiques of any changes to the billing address, expiration date and/or changes to the credit card account provided. Any information provided in this form will be used for the completion of any orders submitted to us.

CREDIT CARD AUTHORIZATION

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