AMK Auto Parts Sales & Service Inc.

425 John Ward Rd. Lexington, NC 27295

Phone: 336-237-0885 Fax:336-217-8030
amkautoparts@gmail.com

Credit Card Authorization

Print and Fax Back

I ____________________________________ authorize, AMK Auto Parts Sales & Service to charge my

(Visa/MC/Discover/AE) _______________________Credit Card.

Billing Address (Name):________________________________________

Street Address:________________________________________________________________________

City:____________________State:___________Zip Code:___________

Shipping Address (Name):______________________________________

Street Address:__________________________________________________________________________

City:____________________State:___________Zip Code:___________

Phone:_____________________________________

Parts Description:__________________________________________________________________________

________________________________________________________________________________________

Front Copy Of Card Here Copy Of ID Here

Name (as it appears on the credit cards): ________________________________________________

Credit Card # ______________________________________________Expiraion Date ____________
Security Code:_______________ (on back of credit card)
In the Amount of $ ____________________________ For AMK Auto Parts Sales & Services Inc.

Print Name: ______________________________________________ Date:_____________________

Authorization Signature: _______________________________________Date:___________________