Credit Card Authorization Form
Mike Moore’s Auto Salvage
(386)-673-4351 Fax


I, ____________________, authorize Mike Moore’s Auto Salvage to charge the following credit card for the specified amount.
Price for Parts $___________
Tax $______________***
Shipping $________________
Total $________________

***Please fax copy of TAX CARD if Tax Exempt

Card Type (circle one):     MC   VISA   DISCOVER   AMEX

Card Number: ________________________________________
Expiration Date: ___/___/___ CCV Code____
Card Holders Name: ________________________________
(Exactly as it appears on the credit card)

Billing address: ________________________________________
City: _____________________
State: ______ Zip: __________
Card Holders Phone Number: ( )-_____-___________

Card Holder Signature: ______________________
Card Holder Name (print): ______________________
Date Of Signature: _____/____/____________

Year and Make of Vehicle ________________________________
Part Ordered: _________________ Part # ___________________
Please specify if part is Left or Right side if applicable. No guarantee on colors.

Shipping Address:
Name ________________________________________________
Address ______________________________________________
City ____________________State _______Zip ______________
Business Phone # ________________________________________________

All returned parts are subject to a 25% restocking fee. Shipping charges are NOT REFUNDABLE. (No exceptions) In the event the customer wants to return the part, he/she will be responsible for ALL shipping charges.