AFFORDABLE AUTO SALVAGE

4100 South Military Trail Lake Worth, Florida 33463

RETURN VIA FAX: 561-965-3243

HAVE A QUESTION? CALL 800-771-2640

CREDIT CARD AUTHORIZATION

 I___________________________________________________ hereby authorize

Affordable Auto Salvage to charge my credit card as follows:

*Credit card type:___________ Visa – MasterCard - Am Ex - Discover

*Credit card number:_________________________________________________

*Expiration date:_____________________

*V Code:__________ (Last # digits shown on the back of your card)

*Credit Card Billing Address:__________________________________________

__________________________________________________________________

*SHIPPING ADDRESS:______________________________________________

__________________________________________________________________

*Name as it paper’s on the card:________________________________________

*Work phone #:__________________ Home phone#:_______________________

___________________________________           __________________________

*Card holder's signature                         *Date

**** NO REFUNDS!! NO EXCEPTIONS!!***

PLEASE SEND A COPY OF YOUR CREDIT CARD AND PHOTO I.D.

I hereby certify that the above statements & information are

true and correct to the best of my knowledge. I also certify

That I am authorized to effect charges to the above card.

***********To be completed by the salesperson***********

Amount to be charged: $_________________ U.S. Dollars

Includes freight charges &/or tax if applicable.

Year:_____________  Make:________________ Model:_________________________

Description of the part:____________________________________________________