Credit Card Authorization Form
Alabama Boating Supplies/ www.BiminiTops.biz 256-619-0130 Phone
PO box 516
Geraldine, AL 35974
I hereby authorize D Duke Enterprises LLC, to charge my credit card account in the amount of $_________________
Printed amount $_______________________________________
( )VISA ( ) MasterCard ( ) 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 Alabama Boating Supplies, aka 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. Alabama Boating Supplies 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 your state or Government issued ID.
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 email to: forms@biminitops.biz
Copyright 2011 Alabama Boating Supplies. All rights reserved
BiminiTops.biz
Printable mail and FAX in order form.
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Make Check or money orders payable and mail orders to:
Biminitops.biz
Po box 516
Geraldine, Alabama 35974
256-619-0130
Right click on this page and select "print "
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Payment Enclosed=>
Signature of Card holder:
I authorize BiminiTops.biz to charge this card the amount listed
above Plus applicable shipping (if applicable):
Sign______________________________________________________
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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
description/ color
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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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Card Number:
- - -
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Expires
_____/_____
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3 Digit code on
back__________
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The "3 digit code" is the last 3 numbers in the signature line. 4 numbers for AMEX.
We accept, Visa, MC, American Express, or Discover.
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Bill me Via Pay-Pal checkout =>
We Can ONLY ship to the address on the Credit Card.
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Pay By Credit Card -Type of card: Master Card___ Visa___ DIS____ AMEX___
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Comments or Special Instructions:
Alabama residents must add 8% sales tax!
Call 1-888-458-2628 for assistance.
Total Payment Amount____________
If you need
more lines for
items, please
use a separate
sheet of paper
and fax it along
with this one.