Third Party Pick Up Authorisation Form
You MUST fill in this form if you are arranging a store pick-up with a third-party person or courier service.
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Order Total
*
The total amount of this transaction
Authorised 3rd Party Pick Up Details
*
First Name
Surname
Company (If Applicable)
Pick Up Date
*
-
Day
-
Month
Year
Date
Attach a photo of your drivers license or photo I.D
*
Browse Files
Drag and drop files here
Choose a file
Your data is for office use only
Cancel
of
Attach a photo of your Credit Card showing the cardholder's name
*
Browse Files
Drag and drop files here
Choose a file
Your data is for office use only
Cancel
of
Signature
*
Person picking up the order on your behalf MUST provide our staff with a photo I.D for approval.
Submit
Should be Empty: