PACIFIC AUTO SALVAGE, INC.

5759 BROADWAY  HWY 29

AMERICAN CANYON, CA  94503

TEL: 707-255-1437

FAX: 707-255-1281  

Attn: Heather

AUTHORIZATION TO CHARGE CREDIT CARD ACCOUNT

I THE UNDERSIGNED GIVE PERMISSION AND AUTHORIZE

PACIFIC AUTO SALVAGE, INC.

5759 BROADWAY  HWY 29

AMERICAN CANYON, CA. 94503

TO MAKE THE FOLLOWING CHARGES ON MY CREDIT CARD ACCOUNT NAMED

(PLEASE PRINT CLEARLY)

TYPE OF CARD: VISA ______ MASTERCARD ______ DISCOVER ______ AMERICAN _____

                                                                                                                                       EXPRESS                     

ACCOUNT NUMBER:___________-___________-___________-___________

EXPIRATION DATE: ____________ / ____________     

LAST 3 NUMBER CODE ON BACK OF CREDIT CARD: _________________

NAME ON CARD: _________________________________________________

BILLING ADDRESS: _______________________________________________

CITY: _________________________ STATE: _______________ZIP: _________

TELEPHONE HOME: ___________________ WORK:_____________________

DRIVERS LICENSE NUMBER: __________________________STATE_______

SHIPPING ADDRESS IF DIFFERENT THEN BILLING ADDRESS:

SHIP TO NAME:___________________________________________________

ADDRESS:________________________________________________________

CITY: ____________________________ STATE: __________ ZIP: __________

PARTS ORDERED ARE:_____________________________________________

PRICE:_____________________  THE PRICE INCLUDES PARTS, APPLICABLE TAX, AND SHIPPING / HANDLING COSTS.  SHIPPING / HANDLING COSTS ARE NOT REFUNDABLE.  

SIGNATURE:_______________________________________________________

PLEASE FAX BACK TO PACIFIC AUTO SALVAGE, INC.    (707) 255-1281