CREDIT CARD PAYMENT AUTHORIZATION

I,   authorize
to charge the sum of :

(in letters)

TO: Visa   Master Card   Amex
Card Number :               Expiry Date :
Please fill in the last three-digit number (for VISA card) or four digit number (for AMEX) appearing on signature panel:

My name as appear on the card is :

The above mentioned charge is for :

Card Holder’s Signature :
_________________________
Date:
Cardholder's Address :
Cardholder's Tel. No : Area Code   No
Cardholder's Fax No : Area Code   No
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 nicolasimbari.com: (718) 375-0965