Collectables Galore Credit Card Purchase Agreement
The following is payment for order number:
Name and address of person as it appears on the credit card invoice sent each month:
Given Name:
Family Name:
Apt/Unit:
Mailing Address Line 1:
Mailing Address Line 2:
City:
State/Province/Territory:
If other:
PC/ZIP:
Country:
If other:
Please complete the following:
Telephone Number: --- Area Code Telephone No.
If different format:
Fax Number: --- Area Code Fax No.
If different format:
E-Mail Address:
Credit Card:
Amount to be charged to this credit card in U.S. Funds: $
Provide credit card information just as it appears on the card:
Credit Card Number:
Expires on:
Name of person on credit card:
3 digit security code on back of card - last 3 numbers:
Today's date:
PRINT THE FORM - then sign
Credit Card Holder's Signature:
Once the form is completed, printed and signed, fax to: 1 - 204 - 753 - 2518
