Stagecoach Wrestling Products™2011

Credit/Debit Card Authorization

Visa, MasterCard, America Express

Mail Orders thru the U.S. Postal Service to: P.O. Box 443, Milton, FL 32572

If you have any questions as you are filling this out call the shop at: (850) 626-3579

Visa/ Mastercard Number:

__ __ __ __--__ __ __ __--__ __ __ __--__ __ __ __ Expiration Date:__________

American Express Card Number:

__ __ __ __--__ __ __ __ __ __--__ __ __ __ __ Expiration Date: ____________

Card Holder's Name : ________________________________

Billing Address:

Street________________________________________Apt.#______________

City,__________________________State__________ Zip______________

Payment Amount $________________

Signature of Card Holder_____________________________________

*Send a Photo-copy of the card front and back and your I.D. with this form*

To help preserve your rights mail a printed copy of this form to us. Do not e-mail this information.

*Unauthorized use of credit/debit card information is fraud*

This form and all of the information contained within are the copyrighted property of Stagecoach Wrestling Products and Roy Roger Bullard 1998-2011