planilla autorizacióncargo en

REX SUPPLIES LLC
2148 ORINOCO DR. SUITE 312, ORLANDO FL. 32837 EEUU
AUTORIZACION DE CARGO TARJETA DE CREDITO
CREDIT CARD AUTHORIZATION FOR NEW CUSTOMERS
NOMBRE TARJETAHABIENTE: ____________________________________________________
NAME ON CARD
NRO. TARJETA: ________________________________________________________________
CREDIT CARD NUMBER
FECHA EXPIRACION: _________/__________
EXPIRATION DATE
VISA (
)
MASTERCARD: (
CVV2: _________________________
CW2
)
AMERICAN EXPRESS: (
)
DIRECCION CORRESPONDENCIA: _____________________________________________________
BILLING ADDRESS:
__________________________________________________________________________________
CODIGO POSTAL: ________________
ZIPCODE
TELEFONO: ___________________________
PHONE NUMBER
E-MAIL: :_____________________________________________________________
ESTA ORDEN ESTA REALIZADA POR EMAIL O POR FAX . YO AUTORIZO A REX SUPPLIES LLC A CARGAR
EN MI TARJETA EL MONTO QUE APARECE EN $_________________
THIS ORDER IS BY EMAIL OR FAX. I AUTHORIZE REX SUPPLIES LLC TO CHARGE MY CARD IN THE
AMOUNT THAT APPEARS ON $ ____________________
FIRMA:
SIGNATURE
___________________________________________________
LA FIRMA DEBE COINCIDIR CON LA IDENTIFICACIÓN SUMINISTRADA
CON FOTOGRAFÍA
SIGNATURE MUST MATCH THE SUPPLIED PHOTO IDENTIFICATION
REX SUPPLIES LLC MAY USE DIFFERENT METHODS TO VERIFY THE INFORMATION, INCLUDING, BUT
NOT LIMITED TO, DUNN AND BRADSTREET REPORTS CREDIT BUREAU REPORTS, AND GOVERNMENTSPONSORED INFORMATION WEB SITES.
NOTA: ANEXAR COPIA DE LA TARJETA DE CREEDITO POR AMBOS LADOS AL IGUAL QUE UNA
IDENTIFICACION PERSONAL.
NOTE: ATTACH A COPY OF CREDIT CARD BY BOTH SIDES AS WELL AS A PERSONAL IDENTIFICATION.