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Atantica, Inc., 1185 Chess Dr., Suite C Foster City, CA 94404 TEL: 650.578.2800 FAX: 650.578.2804 |
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Credit Card Authorization Form |
| I, _______________________________,
hereby authorize Atantica, Ltd. to charge my credit card account in
the amount of $_________.
As the credit card holder, I hereby authorize receipt of merchandise at the shipping address below. |
| VISA | MASTERCARD | AMERICAN EXPRESS |
| Credit Card Number: | |||
| Expiration Date: | |||
| VID Code: | |||
| Credit Card Billing Address | |||
| Company: | |||
| Name: | |||
| Street: | |||
| City: | |||
| State: | |||
| Zip Code: | |||
| Country: | |||
| Telephone: | Fax: | ||
| E-Mail: | |||
| Requested Shipping Address (if different than billing address) | |||
| Company: | |||
| Name: | |||
| Street: | |||
| City: | |||
| State: | |||
| Zip Code: | |||
| Country: | |||
| Telephone: | Fax: | ||
| E-Mail: | |||
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Cardholder's Signature________________________ Date: ___ / ___ / ___ |
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