Blades and Brights - Charity Chimni – Online Knife Dealer

                      PO Box 1281

Rockwall, Tx 75087

Phone: 972-325-1275

Fax: 972-636-5685

charitychimni@gmail.com

www.bladesandbrights.com

Credit Card Authorization Form

All information will be kept in strict confidence and used only by Blades and Brights/Charity Chimni. THIS FORM CAN BE REJECTED DUE TO INCOMPLETE ANSWERS TO THE FOLLOWING QUESTIONS.

Customer Information:

Customer Name: _______________________________________________________________

Forum Name / Forum Alias: _____________________________/________________________

Email Address: ________________________________________________________________

Credit Card Information:

Card Type (Check One):  [   ] VISA    [   ] MASTER CARD    [   ] Discover

Credit Card # __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Exp. Date(mm/yy)  ____/____

Card Verification # (Last 3 numbers on the back of the card) __________

Cardholders Name (As printed on the card) __________________________________________

Credit Card Billing Information:

Address         ____________________________________________________________

                      ____________________________________________________________

Postal Code  ____________________________________________________________

Country         ____________________________________________________________

Phone            ____________________________________________________________

Shipping Address (If different from Billing Address):

Address         ____________________________________________________________

                      ____________________________________________________________

Postal Code  ____________________________________________________________

Country         ____________________________________________________________

Reason for different addresses: ____________________________________________

Signature:

I agree to have the total amount of the invoice billed to my above listed credit card, I further agree to pay the total amount in accordance with the Card Issuer Agreement.

X______________________________________________________________________

Card on File:

[   ]  Check here to have Charity Chimni retain this credit card information for future purchases.

Fax/email completed form to Charity Chimni at 972-636-5685 / charitychimni@gmail.com