Credit card Authorization form

Customer Information

Name

Address

City

State                                    Zip code

Phone # daytime                           Evening

E-Mail address

Credit card information    (circle one)

Visa                    Mastercard              Amx

Credit card #

Expiration Date  mm/yr

Security code (last 3 # on the back)

Billing Address on the card

city                                     State                          Zip code

I here by authorize Aqua-holics to charge my credit card for  1  on- line placed order

Authorized Signature:

Please send a list of ordered item (s) along with fax  and you will receive a conformation email with a total including shipping  before the items are charged to your account   Credit cards are processed through our in store merchant account.  We will send a shipping conformation # Items ususally ship the next business day after processed

Please fill in this form and fax it along with your order to:

1-407-483-0357     Aqua-holics    1166 E. Donegan Ave.  Kissimmee, Fl. 34744  phone # 407-483-0344    E-mail Aquaholics@cfl.rr.com       Do NOT e-mail this Form ad E-mail is NOT secure

Use this form only if you do not want to process your order through Pay pal

If you do not have a Paypal account   you can set one up as you go throught the check out process on the shopping cart processing and use your major credit card throught pay pal It only takes a minute.    your order and payment will be forwarded to me by Paypal