3848 Burlington Rd

Greensboro, NC 27405

336-375-5871 800-451-0693

FAX: 336-375-6415

Credit Card Authorization Form

DATE:________________ PAYMENT ON ACCOUNT? YES____ NO____

NAME AS IT APPEARS ON CARD:_________________________________________

CARDHOLDER’S ADDRESS:______________________________________________

______________________________________________________________________

SHIPPING ADDRESS IF DIFFERENT:_______________________________________

CARDHOLDER’S PHONE #:_______________________________________________

I/WE AUTHORIZE Tri City Auto Salvage, Inc. TO CHARGE MY CREDIT CARD

AMOUNT OF CHARGE: $___________________________

ACCOUNT NUMBER:______________________________________________

EXPIRATION DATE:_______________________________________________

CARD TYPE: VISA _____ MASTERCARD _____

CARDHOLDER’S SIGNATURE:________________________________________

DESCRIPTION OF PART:______________________________________________