| Credit Card Authorization for: WHEELS AUTO RECYCLERS. LTD 1021 W. FM 6 Nevada,Tx 75173 Tel.-972-843-2667 Fax-972-853-0600 Purchase authorization to use credit card Date:____________ Card Holder Name:____________________ Billing address:______________________ Home Phone # _____________________ ________________________ Work Phone #_________________ ______________________ Fax#_____________________ Credit card #________________________________ Expiration date___________ CVVC#______ Type of Credit Card Visa Mastercard American express Discover other ========================================================================= Ship to : __________________ contact:___________________ address: __________________ City:_________ State:___________ Year________ Make__________ Model________ Part type __________________ Description:_______________________________ V.I.N._______________________________ LH_____ RH_____ Notes______________________________________________________ ___________________________________________________________________________________ ================================= I hereby authorize Wheels Auto Recyclers to charge the order described above on credit card as noted above. I understand that this order is placed via telephone and my signature on this agreement is binding. This purchase is for used parts , I understand that if for any reason i refuse this shipment the freight charges will be charged to my credit card. These parts carry a 90 day warranty unless noted in writing Part price$_________ Freight quoted$________________ Total Price to be billed $_____________ Card holder signature:___________________________ |