Company/ Individual Name: _________________________________________________
Phone number:__ __ __-__ __ __-__ __ __ __
Billing Address (for card): Physical Address (no PO Boxes):
Street: ____________________________ Street:_______________________________
City: ______________________________ City: ________________________________
State: _______ Zip: _______________ State: _______ Zip: _______________
Credit Card Information:
Full Name on Card: ________________________________________________
Last 4 Digits of Card Number: ____ ____ ____ ____
Expiration Date: _______ / ____ / _______ V Code: ___________
I, ____________________________________ (print name) am authorized to make purchases with the card I have listed above. Further, I would like to authorize the purchase(s) from B & B Auto Parts on invoice/work order# __________ for the amount of $___________.
____________________________________________ ________ / ______ / ________
Card Holders Signature Date Signed
---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- Please provide the full card number below on the provided line. This portion of the fax will be destroyed upon completion of this transaction. The top portion is retained for our records. Thank you for understanding this security measure and helping B & B Auto Parts to protect your identity and prevent credit card fraud.
____________ / ____________ / ____________ / _____________
Full Credit Card Number
