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1495 3rd Avenue West, Shakopee, MN 55379 Phone: 855-445-2300 - Fax: 952-445-1317 - E-mail: [email protected]
Credit Card Charge Authorization Form
Your completion of this authorization form helps us to protect you, our valued customers, from credit card fraud. All information entered on this form will be kept strictly confidential. All orders paid by credit card or orders to be shipped to an address different from the billing address, we need to obtain your written authorization. Note: We accept the following credit cards: MasterCard, Visa, Discover, and Debit.
1) Fill out and print or print the blank form and complete the entire form legibly with a dark pen. Card holder mustsign on the line indicated. We reserve the right to verify the provided information with your Credit Card Issuing Bank.
2) Include a photocopy of the front and back of the signed credit card.
3) Fax (952) 445-1317 or scan and e-mail to [email protected] the completed form and the photocopies of the credit card tocomplete your order.
Directions:
Name
Address
City State Zip Code
Company
Phone
Name
Address
City State Zip Code
Country
Company
Phone
Billing Address: Shipping Address:
Shipping Method:Order Number:
Comments:Product Description / Product Name: QTY. Unit Price Amount
Total:
Shipping & Handling:
Sales Tax :
Subtotal:
Credit Card #: /
Credit Card Information
CVV:
* CVV is the last 3 digits on the back of your card.
I, ______________________________, understand the company policy and hereby authorize North Imports Auto Parts, LLC to charge my
credit card account in the amount of $_______________ for the products listed above, applicable taxes and shipping and handling charges.
I agree to be bound by North Imports Auto Parts, LLC. policies, terms and conditions, and instructions for this transaction.
I have read and understood Customer Warranties & S&H costs and I agree to North Imports Auto Parts, LLC Warranties and S&H on orders.
Signature: Date:
Bank Name:
Expiration Date:
Bank Phone:
North Imports Auto Parts, LLC
Year / Make / Model / Engine / Manual or Auto VIN *Helpful for part verification and required for some parts.
*Details help make sure we match the correct parts.
