Silvex International, Inc.
640 S. Hill # 246
Los Angeles, Ca 90014
TEL 213-362-6951
FAX 213-622-2657
Credit Card Authorization
Date______________
Company Name___________________________________
Name As It Appears on the Card__________________________________
Cardholder's Billing Address__________________________________________________
Address
___________________________________________________
City, State and ZIP CODE
Contact Phone Number For Cardholder ____________________________
Visa/MC/Amex#_________________________________Expiration Date___________
CVV# (for VISA & M/C back of card________ CID# ( for AMEX
front of card)____________
**I authorize Silvex International Inc. to charge my Visa/MC/Amex
for all further purchases of merchandise shipped.
I understand that this is your written authorization to charge these
shipments to my charge cards indicated above. This agreement is valid
until written notice of cancellation is received.
Cardholder's Signature X__________________________
If cardholder's billing address is outside of the US, please also
provide 1) a photocopy of the front and back of the credit card, 2)
a photocopy of the cardholder's passport or identification card, AND
3) the information below for the card-issuing bank. Thank you!
Name of Bank: _____________________________ Telephone No. ____________________
Address of Bank: _________________________________________________________________
To cancel the above Charge Card Authorization, please provide
the information below.
This is my authorization to CANCEL the above agreement:
Company Name: _______________________
Credit Card Holder: ____________________
Date Of Cancellation: ___________________