CREDIT CARD AUTHORIZATION

CREDIT CARD AUTHORIZATION FORM

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.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

CREDIT CARD AUTHORIZATION FORM

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