Southwest Mitsubishi Parts & Service

Parts & Service Department

Authorize it!
IMPORTANT NOTICE

Please note that any payment submitted AFTER business hours will not be processed until the FOLLOWING business day. This includes payments made late night, weekend, and/or holidays.

MAKE SURE TO SUBMIT YOUR PHOTO PROOFS AS REQUESTED BELOW

Thank you for utilizing this form, your patience, and payment.
Purchase Order Number (PO):
Your Name*

First NameLast Name
Your Email
example@example.com
Payment Option (Please confirm your one-time payment)*
Exact $ Amount to Charge*
Exact Date to Submit Charge

MonthDayYear
Charge Date
PLEASE UPLOAD PROOFS
Individual / Personal Documentation Submission (Non-Business Entity)

FOR INDIVIDUAL CUSTOMERS WHICH ARE NOT A BUSINESS OR COMPANY.
Upload front credit/debit card picture

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Upload back credit/debit card picture

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Upload DRIVER'S license front picture

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Upload misc documents (if requested)

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IF YOU ARE SUBMITTING THIS PAYMENT ON BEHALF OF SOMEONE ELSE, Please type their full name (First/Last) here:
Message / Additional Info (if any)
Your CC Billing Address*
CC Expiration Date (Month/Year)*
I, {cardholderName}, hereby authorize Southwest Mitsubishi, aka Sapney, Inc, aka Kar Market, DBA, and their successors, assigns, affiliates, subsidiaries, new acquisitions, and joint ventures, regardless of which name they operate under, to charge the above credit card and agree to pay per the retail installment contract and/or repair order, for the account of the customer named in retail installment contract/repair order, according to card issuer bank cardholder agreement and/or merchant agreement, and agree not to dispute this document indicating authorization. I confirm that the information for the credit card and billing address is complete and accurate.
Today's Submission Date

MonthDayYear
Date
Your Signature

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Please verify that you are human*
Should be Empty:

Parts & Service Department

Individual / Personal Documentation Submission (Non-Business Entity)