CREDIT CARD PAYMENT AUTHORIZATION

I,   authorize Bos Auto Parts,3955 County Rd 42,Windsor Ontario,N9A6J3
to charge the sum of :

(please indicate currency)

(in letters)
TO: Visa Card
 Visa		  Master Card
 Master Card
 
  
Card Number :               Expiry Date :
Please fill in the last three-digit number (for VISA card)  appearing on signature panel: (see example)

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 : Country Code   No
Cardholder's Fax No : Country 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 Bos Auto fax# 519-972-1911