Credit Card Authorization Form - Reitman Auto Parts & Sales

Credit Card Authorization

"*" indicates required fields

Name As It Appears On Card*

Your Name*

Phone*

Email*

Company Name

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Are Billing & Shipping Address the same*

Note: For any purchase over $500 credit card address and shipping address MUST match.

Yes

Shipping Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Year*

Make*

Model*

Parts Purchased*

Credit Card Type*

Visa

Mastercard

Credit Card Number*

Expiration Date*

Security Code*

Last 3 Numbers on Back of Card

Amount to Charge Card*

Please enter a number less than or equal to 5000.

Toll-Free Number on Back of Card*

Note: For any charges over $500.00, credit card and shipping address MUST match.

*We reserve the right to request a copy of your photo ID and photo of credit card, front and back.

*Reitman Auto Parts & Sales reserves the right to cancel any credit card transaction.

Note: If you are a resident of The Commonwealth of Kentucky, we are required by law to charge you sales tax of 6%. on the part and on shipping.

Signature*

Date*