planilla autorizacióncargo en
Transcripción
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.