CC Auth

CREDIT CARD AUTHORIZATION AGREEMENT
THIS AGREEMENT IS REQUIRED TO PROTECT THE CARD HOLDER AND OURSELVES FROM CREDIT CARD FRAUD.
Please follow these directions.
1. The back of your credit card must be signed for us to process your order.
2. Include a copy of the front & back of the credit card, as well as the Photo ID card holder.
3. Please complete the entire form below and fax it to: 303-997-5642

Credit Card #(Required)

Card Type(Required)

Visa

M/C

Discover

AMX

Exp Date (MM/YY)(Required)

CVV Code(Required)

Name as it appears on card(Required)

Address(Required)
Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Signature(Required)

Date(Required)
MM slash DD slash YYYY

Blanket Agreement
Yes
In selecting Blanket Agreement, I agree & authorize that my credit card will be used for future transactions until I rescind this authorization in writing.

Single Use Agreement
Yes

Front of Card Image(Required)
Max. file size: 10 MB.

Back of Card Image(Required)
Max. file size: 10 MB.

Cardholder ID Image(Required)
Max. file size: 10 MB.

CC Auth

Title

NEWSLETTER

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