BluebellWholesale

BLUEBELLWHOLESALE.COM
90 DAYTON AVE Bldg 9-4H
PASSAIC, NJ 07055
TEL: 201-804-0111, FAX:201-804-7830

BILL TO / SHIP TO ADDRESS AUTHORIZATION FORM

COMPANY NAME:
BILL TO: (Credit Card Information) SHIP TO:

NAME:

ADDRESS:



PHONE #:

NAME:

ADDRESS:



PHONE #:
* The information given on the BILL TO: must match the information you've provided to your credit card company.

PLEASE GIVE FOLLOWING INFORMATION TO VERIFY YOUR CREDIT CARD TRANSACTION
NAME OF CARD ISSUING BANK:

BANK'S TOLL-FREE TEL # PRINTED ON CARD (BACK):

YOUR EMAIL ADDRESS:

* Incomplete informatin will delay your order. We may need to contact you if there are any problems with your order.

AUTHORIZATION AND CONFIRMATION SIGNATURE
I,                                                             (card holder's name) authorize
Bluebellwholesale.com to charge this order to my account and to the above shipping address:

Signature:                                                                       Date: