Credit Card Authorization Form

Your completion of this authorization form helps us to protect you, our valued customers, from credit card fraud.  All information entered on this form will be kept strictly confidential.

As the Authorized Credit Card Holder, I    authorize
VistaWholesale.Com to charge my credit card listed below for purchases made through my www.VistaWholesale.Com Customer Account.
VISA

Master Card

American Express/Discover

Credit Card Number:

Expiration Date:  /       


 

Credit Card Billing Address:
Name:       
Address:  
Address 2:
City:         
State:          Postal Code: 
Country: (if not USA)
Province:    
Telephone:    () -         
Photocopy Front of Credit Card

Requested Shipping Address:
Name:       
Address:  
Address 2:
City:         
State:          Postal Code: 
Country: (if not USA)
Province:    
Telephone:    () -         

Photocopy Back of Credit Card  Photocopy PHOTO ID (ie Drivers License)

 



__________________________________    ____/____/______
Cardholders Signature                        Date

IN ORDER FOR THIS FORM TO BE VALID, YOU MUST INCLUDE A COPY OF THE FRONT AND BACK OF THE CREDIT CARD SHOWING YOUR NAME, SIGNATURE AND CARD NUMBER, AS WELL AS A COPY OF A PHOTO I.D.

Do not forget to

This Form and FAX to (775)249-2716
OR
You can scan the information and send via email to info@vistawholesale.com