Credit Card Authorization Form - SCOTT'S USED PARTS

Order Number/Item Description

Ordered From:

Select OneDaveScottKelleyOther

Type of Card Being Used:

Select OneVisaMastercardDiscoverAmerican Express

Credit Card Number:

Expiration Date:

CVC Security Code (*Last 3 digits on the back of the card.):

Please Upload a Copy of Your Photo ID:

Credit Card Billing Address

First and Last Name

Street

City

State

Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code

Phone

Requested Shipping Address

First and Last Name

Street

City

State

Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code

Phone

Cardholder's Signature

Email:

Date:

As the credit card holder, I hereby authorize Scott's Auto Inc. to charge my credit card in the amount of purchase (including shipping and/or taxes, if applicable).

As the credit card holder, I hereby authorize receipt of merchandise at the shipping address above, and agree to vendor's in store policies.

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 by our company.