T-Shirt Shoppe Credit Card Authorization Form

PRINT THIS FORM OUT - SIGN BELOW, Include
A PHOTOCOPY front & back of your SIGNED credit card
belonging to the credit card holder Below.
We also need a PHOTOCOPY front & back of your
Driver's License belonging to the card holder below:
FAX THIS FORM TO: 1-815-327-3702
Please complete in FULL or your order may be delayed
BUSINESS OR SCHOOL NAME:_____________________________________________
Primary Address for Shipping:
Street Address______________________Business Phone___________________
City, State, Zip:___________________Box Number_______________________
Contact Name:________________________________________________________
Billing Address of the Credit Card or PO# Used:
Street Address______________________Business Phone___________________
City, State, Zip:___________________Box Number_______________________
I hereby authorize T-Shirt Shoppe to use my credit card for
purchases made from the T-Shirt Shoppe. I understand that my
credit card will be charged before goods will be released.
This agreement will be in effect unless and until revoked by signer
on the credit card account or school purchase officer.
Credit Card/PO #___________________________O Visa O M/C O Discover
Check One Above
Issuing Bank ________________________ Physical Signature____________________
Title: _________________________Today’s Date_________________________