CREDIT CARD PAYMENT AUTHORIZATION

B.O.S. Auto Parts - Fax Payment Form - Please fill out and fax to 519-972-1911

IMPORTANT: Instructions on How to Use This Form

1) Kindly fill your credit card type, card number, name on card, expiry date, plus the last 3 or 4 digits on the back of your card (depending on your card type)
2) Print out the form and verify that all details are correct, then please sign your name on the "Card Holder's Signature" line
3) Fax authorization form, along with copy of the credit card on both sides to B.O.S. Auto's Fax Number 519-972-1911 or email to: office@bosautoparts.com
I,   authorize B.O.S. Auto Parts,
to charge the sum of :

(sum in letters)

TO:  Visa Card
Visa
 Master Card
Master Card
*Private customers must provide a copy of their driver's license.*
 
 
Card Number :               Expiry Date :
Please fill in the last three-digit number appearing on signature panel: (see example)

My name as it appears on the card is :

The above mentioned charge is for: (Please fill out after printing)
Item Description Amount Subtotal ____________________________
1 ____________________________ ____________________________ Shipping Charge ____________________________
2 ____________________________ ____________________________ Taxes ____________________________
3 ____________________________ ____________________________ Total ____________________________
4 ____________________________ ____________________________ Initials _________________

Card Holder's Signature :
_________________________
Date: (Month/Day/Year)
U.S. and Foreign Customers Only: IRS Number: Social Security Number: Import/Export Number:
Cardholder's Address :
Cardholder's Tel. No : Area Code   No
Cardholder's Fax No : Area Code   No