| Date:______/______/______ |
Sale Amount: $___________________ |
Account Number:__________________________ |
Order Number:___________________ |
Billing Address:____________________________ ________________________________________ ________________________________________ |
Ship to:______________________________ ____________________________________ ____________________________________ |
Credit Card Type:__________________________ |
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Card Number:_____________________________ |
Expiration Date:______/______/______ |
Card Holder Name:___________________________________________________________ |
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Authorization Signature:________________________________________________________ |
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CARDMEMBER ACKNOWLEDGES THAT HE/SHE HAS PLACED THE ABOVE LISTED ORDER WITH FRAME USA INC. AND OR FRAMEPLACE.COM. PLEASE BE ADVISED THAT BY SIGNING THE ABOVE AUTHORIZATION CARDMEMBER AGREES TO PAY THE ABOVE TOTAL AMOUNT ACCORDING TO CARD ISSUER AGREEMENT (MERCHANT ARGEEMENT CREDIT VOUCHER) |
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THIS FORM MUST BE SIGNED AND FAXED BACK TO (513) 577-7105 IN ORDER FOR US TO CONTINUE PROCESSING YOUR ORDER. |
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225 Northland Blvd, Cincinnati, OH 45246 |
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Phone:(513)577-7107, Fax:(513)577-7105, Toll Free:(800)666-7654 |
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