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| MOPED WORLDŽ P.O. Box 27034 Greenville, SC 29616 USA |
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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 may call to verify order and charges before shipment. We check the validity of all credit cards. Remember to write down your bank's telephone number and sign this form before mailing 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
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