WholesaleDirectUSA.com (WDUSA)
(732) 672-0464
Fax (732) 246-2155
wholesaleDirectUSAcom@yahoo.com
Payment/Authorization Information
Accepted Payment Method
MasterCard, Visa, Discover, American
Express
Invoice # __________________
Card Number _______________________ (enter
number without spaces)
Expiration Date ____________ (mmyy)
Amount __________________
Authorization
Code _______
(right 3 numbers, on the back of visa, master card and
discover.
Four
digits on the top front on American Express card)
Customer Billing Information
First Name _________________ Last Name _______________________________
Company ______________________________________________________________
Address _______________________________________________________________
City ______________________ State/Province ____ Zip Code___________
Phone _________________ Cell _________________ Fax _________________
Email ____________________________________________
Shipping Information
Same
as information entered in Billing Information,
or :
First Name ____________________ Last Name____________________________
Company _________________________________
Address_________________________________________________________________
City ________________________ State/Province _____ Zip Code___________
Phone__________________
_________________________ __________________________ _____________
Signature of Credit card owner Print Name Date
Copies of both sides of Credit card
and the copy of the Driver’s license must be faxed with this authorization for
Credit card processing.