1616 S. Los Angeles Street, Los Angeles, CA  90015

TEL:  (213) 747-7777   FAX:  (213) 745-6046
 

 

READ THIS FIRST: RETURN POLICY

 

 

CREDIT CARD AUTHORIZATION

 

1. COMPLETE THE AUTHORIZATION FORM BELOW AND FAX IT TO (213) 745-6046

2. INCLUDE A PHOTOCOPY OF THE FRONT AND BACK OF THE SIGNED CREDIT CARD.

3. INCLUDE A PHOTOCOPY OF YOUR LATEST DRIVERS LICENSE

 

□ VISA

□ MASTERCARD

□ DISCOVER

 

 Credit Card # :________________________________________________

 

Expiration Date :_______________________              CUV:____________

 

CREDIT CARD BILLING ADDRESS:

REQUEST SHIPPING ADDRESS:

STREET:

  

STREET:

CITY:

  

CITY:

STATE:

  

STATE:

ZIP CODE:

  

ZIP CODE:

COUNTRY:

  

COUNTRY:

PHONE NO.:

  

PHONE NO.:

 

I, ______________________________________, HEREBY AUTHORIZE GAZOZ, INC.

TO CHARGE MY CREDIT CARD ACCOUNT IN THE AMOUNT OF $ _____________________.

 

 

_______________________________

____________________

CARDHOLDER'S SIGNATURE

DATE

 

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