Payment Authorization Form
Customer Details
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Shipping Address
*
Street Address
Street Address Line at 2
City
State / Province
Postal / Zip Code
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Order Number
*
What did you order?
*
Hair Refresh
Create Your Own Wig
Hazel
Aaliyah
Do you agree to authorize this wig purchase?
*
Yes
No
Do you understand that shipping is 14 business days? Business days is Monday- Friday
*
Yes
No
Please type the last 4 digits of the card used to make your purchase
*
Please sign below confirming that you are the owner of the card used to make your purchase
*
Please sign below confirming that you agree to the no returns or exchanges policy
*
Please type the name you signed above.
*
Continue
Continue
Should be Empty: