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COMPANY NAME: |
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BILL TO: (Credit Card Information)
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SHIP TO:
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NAME:
ADDRESS:
PHONE #:
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NAME:
ADDRESS:
PHONE #:
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* The information given on the BILL TO: must match the information you've provided to your credit card company.
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PLEASE GIVE FOLLOWING INFORMATION TO VERIFY YOUR CREDIT CARD TRANSACTION
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NAME OF CARD ISSUING BANK:
BANK'S TOLL-FREE TEL # PRINTED ON CARD (BACK):
YOUR EMAIL ADDRESS:
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* Incomplete informatin will delay your order. We may need to contact you if there are any problems with your order.
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AUTHORIZATION AND CONFIRMATION SIGNATURE
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I, (card holder's name) authorize
Bluebellwholesale.com to charge this order to my account and to the above shipping address:
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