Credit Card Authorization for:
1021 W. FM 6
Nevada,Tx 75173
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:___________________________