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Credit Card Authorization Form

For your protection against fraud, please complete, print and fax the below form to 416.444.3547 or Micropeer Solutions Inc, 333 Lesmill Road, Toronto, ON M3B 2V1

  
 
Date  /   /  (DD/MM/YYYY) Order Amount $ 
Master Card  Visa  PO / Quote # (Optional) 
Credit Card #  Expiry Date   /  (MM/YY)
 
 
  
Cardholder's Billing Information


Name
Address
City
State
Country
Postal Code
Day Time Phone
Fax(Optional)
 
  
Credit Card Issuing Bank Information
(Required only for Non US and Canadian Customers)
Name
Address
City
State
Country
Postal Code
Day Time Phone
Fax(Optional)
 
 
  
Shipping Address
Same As Billing 
Name
Address
City
State
Country
Postal Code
Day Time Phone
Fax(Optional)
 

 

I _______________________ do hereby grant Micropeer Solutions Inc. permission to my above mentioned charge account information to obtain payment for my purchase. The Total product amount is $ _____________ in Canadian / US.

Plus Shipping 
Plus Handling 

Cardholder's Signature _____________________

Date : _______________