Credit Card Authorization Form

Complete this form and fax to USA 405-842-4700 

On a separate page, include a copy of:

     1. Credit card, front and back.  Set copier to light or image will appear to dark to read.

     2. Copy of photo ID, such as driver’s license or Passport. 

ORDER NUMBER / COMPANY NAME ________________________________ (if applicable)

  I, _________________________, hereby authorize SpeedSupplies.Com to charge my credit card account in the amount of $_____________.

□ Visa      □ MasterCard      □ American Express      □ Discover      □ Debit Card

Credit Card # __________________________ Exp Date:  ____ / _____

SHIP TO OTHER ADDRESS

Credit Card Billing Information

Requested Shipping Address

Name: _____________________

Name: ______________________

Street: _____________________

Street:  _____________________

City:  ______________   State:___

City:  ______________   State:___

Zip Code:  ____________

Zip Code:  ____________

Telephone:  (____) ____-________

Telephone:  (____) ____-________
I hereby authorize delivery of merchandise to the shipping address above which is not my credit card billing address.  I agree that I will pay for this purchase and indemnify and hold SpeedSupplies.Com  harmless, against any liability pursuant to this authorization.  I understand that my signature on this form along with a copy of my credit card and a picture I.D. will serve as my authorized signature on the credit card charge slip. I understand and agree to the terms and conditions as outlined at www.speedsupplies.com/policies.htm and all sales are final after 30 days.

SIGNATURE RELEASE
SpeedSupplies.Com requires a signature upon delivery unless a waiver is authorized.
I hereby authorize merchandise to be left at my credit card billing address or other shipping address as indicated above without obtaining a signature.  I agree that I will pay for this purchase and indemnify and hold World of SpeedSupplies.Com harmless, against any liability pursuant to this authorization.  I understand that my signature on this form along with a common carrier delivery notification will suffice as proof of delivery.

Print Cardholder's Name _________________________________________________

X__________________________________

____/____/______

Cardholder's Signature

Date

Return policy: All sales are final after 30 days.  30% Restock fee on Special Order Items.

Fax completed form, copy of credit card and photo ID to 405-842-4700