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Print this page and return completed to JWA Enterprises To: JWA Enterprises Telephone: (724)-428-3070 Fax: (724)-428-4453 From:___________________ Telephone:_____________ Fax:_____________________ CREDIT CARD AUTHORIZATION CONTRACT I AUTHORIZE JWA ENTERPRISES TO CHARGE MY (CHECK ONE) MC___ VISA___ AMERICAN EXPRESS___ DISCOVER/NOVUS___ THE CARD NUMBER IS:________-________-________-________ EXPIRATION DATE:______-______ THE CHARGE IS FOR MY ORDER TO JWA ENTERPRISES FOR THE TOTAL U.S. DOLLAR AMOUNT OF:$______________ (PLUS SHIPPING CHARGES) I understand that my signature on this contract will serve as my authorization for JWA Enterprises to electronically charge my credit card for the above amount plus shipping charges. Signature of card holder_____________________________________ Date:______________________ Print name as it appears on card___________________________________________ Complete Billing Address (Please Print) Street:____________________________________ City:______________________________________ __________________________________________ |
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