Payment Authorization Form
Please fill out this Payment Authorization Form after placing your order.
Legal Name
*
First Name
Last Name
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Upload your ID or Drivers License
Browse Files
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of
Last 4 Digits of Card used to make Purchase
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other
Please Specify
*
Do you understand that shipping and processing
Yes, I understand this
Do you understand that due to the custom nature of this product, that this product is nonrefundable and cannot be disputed.
Yes, I understand this
Do you understand that no changes can be made once the order is placed.
Yes, I understand this
Signature
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