Credit Card Authorization Form
CREDIT CARD AUTHORIZATION FORM
Phone: (310) 769-6060
Email: info@angelusmedical.com
I _______________________ authorize Angelus Medical & Optical to charge my Credit Card.
Contact Name:
Contact Phone No.:
Contact email Address:
Name On the Card: ______________________
Card Type: Visa / Master Card / Discover/American Express (please circle one)
Card No: ___________________ Expiration Date: _____________
Security code: _________________ (4 digits on the front for Amex, 3 digits on the back for all the other ones)
Credit Card Billing address including the zip code: _________________________________________ __________________________________________
I here by authorize delivery of merchandise to the shipping address above which is not my credit card billing address, I agree that I will pay for this purchase and indemnify and hold Angelus Medical & Optical harmless against any liability pursuant to this authorization. I understand that my signature in this form will serve as my authorized signature on the credit card charge slip.
Card Holder Name __________________________________________
Signature __________________________________________ Date ____________________________