Credit Card Fax Order Form

MOPED WORLD®

FAX TO:
Name:_____________________________________ Shipping Address:____________________________ __________________________________________ City:______________________________________ State:__________________ Zip:______________ Daytime Phone #: (______)_______-_____________ Home Phone #: (______)________-______________ Shipping Address must match the billing address. If it doesn't, call the 1-800 Customer Service number located on back of card and set up an "Alternate Shipping Address." Give them the Shipping Address above. Information is kept confidential. We will call to verify receipt of fax within 24 hours. We check the validity of all credit cards. Remember to write down your bank's telephone number and sign this form before faxing it in.	_________________________________________ Account Number on Card _____/___________________________________ Expiration Date Name of Bank Issuing Card _________________________________________ Your name as it appears on Credit Card _________________________________________ 1-800 Customer Service# on back of Card _________________________________________ Your Signature Please Charge my: (Circle One) Visa Mastercard

FAX TO:

Name:_____________________________________

Shipping Address:____________________________

__________________________________________

City:______________________________________

State:__________________ Zip:______________

Daytime Phone #: (______)_______-_____________

Home Phone #: (______)________-______________

Shipping Address must match the billing address. If it doesn't, call the 1-800 Customer Service number located on back of card and set up an "Alternate Shipping Address." Give them the Shipping Address above. Information is kept confidential. We will call to verify receipt of fax within 24 hours. We check the validity of all credit cards. Remember to write down your bank's telephone number and sign this form before faxing it in.

_________________________________________
Account Number on Card

_____/___________________________________
Expiration Date Name of Bank Issuing Card

_________________________________________
Your name as it appears on Credit Card

_________________________________________
1-800 Customer Service# on back of Card

_________________________________________
Your Signature

Please Charge my:
(Circle One)

Visa Mastercard