AMOUNT $______________ Alabama residents must add 8% sales tax! Call
1-888-458-2628 for assistance.
BiminiTops.biz
Printable mail and FAX in order form.
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Make Check or money orders payable and mail orders to:
D Duke Enterprises LLC
1133 Refuge Rd
Ragland, AL 35131
Pay by phone- Phone 205-473-6616 or 1-888-458-BOAT
OR 1-877-AMSOIL7 - FAX orders to 1-800-560-0461
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Payment Enclosed___ E-Bill Me____
Call for payment info.____
Your Name:
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Street Address:
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City, State, Zip:
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Phone:
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E-Mail:
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Item Number:
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Item Number
(use extra sheet of
paper if needed)
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Year of Boat
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Make Of boat
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Model and Model
numbers of boat
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Bill me Google checkout_____
Comments or Special Instructions:
Credit Card Authorization Form
D Duke Enterprises LLC / www.BiminiTops.biz 1-888-458-BOAT (2628)
1133 Refuge Rd. (205 )- 473-6616
Ragland, AL 35131 1- (800) 560-0461 -FAX
I hereby authorize D Duke Enterprises LLC, to charge my credit card account in the amount of $_________________
Printed amount $_______________________________________
( )VISA ( ) MasterCard ( ) American Express ( ) Discover (Check One)
Name on Card: first________________________ Middle I___ Last______________________________
Credit Card Number: ___________--___________--___________--___________
Expiration Date: ________ /________ Phone: ( ) ____________________________
CVV2 Code:___________ (3 digit code on back of card, AMEX has 4 on the front)
Credit Card Billing Address: (ADDRESS #1)
Name___________________________________________________________________________
Address 1:________________________________________________________
Address 2:________________________________________________________
City:_________________________________ State/Providance: _____________________
Zip/ Postal Code: _______________ Country: (if not USA) ________________
Telephone: ( ) _____- __________
Requested Shipping Address: (If same write “Same“) Address #2
NAME___________________________________________________________________________
Address 1:__________________________________________________________
Address 2:__________________________________________________________
City:______________________________________ State/ Providence: __________
Zip/ Postal Code: ___________________ Country: (if not USA) _______________________
As the credit card holder, I hereby authorize D Duke Enterprises LLC, aka www.BiminiTops.biz
to charge my credit card for the amount listed above.
I authorize shipment to address #2 above, if different from address #1.
Your completion of this authorization form helps us to protect you, our valued customers, from credit
card fraud. D Duke Enterprises LLC will keep all information entered on this form strictly confidential.
As the credit card holder. I hereby authorize receipt of goods at the shipping address above.
You must include photo copies of the front and back of you credit card listed above and
a state or Government issued ID. Both Items must include you signature
I AGREE TO PAY ABOVE TOTAL AMOUNT ACCORDING TO CARD ISSUER AGREEMENT
(MERCHANT AGREEMENT IF CREDIT VOUCHER)
Cardholders Signature:_______________________________________________Date_______________
RETURN THIS COMPLETED FORM TO THE ADDRESS ABOVE OR FAX TO 1- (800) 560-0461
Copyright 2007 D Duke Enterprises LLC. All rights reserved