BLUEBELLWHOLESALE.COM 163 E. UNION AVE. E. RUTHERFORD, NJ 07073 TEL: 201-804-0111, FAX:201-804-7830 Bill To/Ship To Address Authorization Form * If you have multiple billing & shipping addresses, please list them all. Bill to: Ship to:     Name: Address:     Name: Address: I,                                                             (card holder’s name) authorize Bluebellwholesale.com to charge this order to my account and to the above shipping address: This time only You may use this form for future orders                                                              Signature                                                              Date                                                              Print Name