Home » Credit Card Authorization Form
*Date:
*Customer:
*Phone:
*Email:
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I authorize Aero Express, Inc. to charge my credit card item(s) shipped against my Purchase Order Purchase Order for the amount of Purchase Amount. A 3% credit card fee will be added to the amount of purchase.
*Name of Cardholder:
Billing Address
Street address and zip code entered below must match the credit card billing address
*Street Address:
*City:
*State:—Select—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
*Zip Code:
*Country:
*Credit Card Type:—Select—VisaMastercardAmerican Express (Amex)Discover
Expiration Date:
Credit Card Number:
Security Code:
*Issuing Bank (on credit card): *Bank Telephone# on card:
*Authorized Signature (type your full name):
7 + 4 = ? By typing my name in the Authorized Signature field, I authorize the business listed above to charge my credit card for the amount(s) described. I certify that I am an authorized user of this credit card and that my electronic signature is legally binding and equivalent to my handwritten signature.
