Rocco's Auto Parts
2121 S. Military Trail
W. Palm Beach FL 33415
1-561-964-6570 FAX

CREDIT CARD AUTHORIZATION

 I___________________________________________________ hereby authorize Rocco's Auto Parts to charge my credit card as follows:

*Credit card type:___________ Visa – MasterCard - Am Ex - Discover *Credit card number:_________________________________________________

*Expiration date:_____________________*V Code:__________ (Last # digits shown on the back of your card)

*Credit Card Billing Address:_________________________________________________________________________________________________

*SHIPPING ADDRESS:____________________________________________________________________________________________________

*Name as it paper’s on the card:________________________________________________________

*Work phone #:______________________________ Home phone#:_____________________________ email________________________________

_____________________________________________           __________________________
*Card holder's signature
                                         *Date

PLEASE SEND A COPY OF YOUR CREDIT CARD AND PHOTO I.D.

I hereby certify that the above statements & information are true and correct to the best of my knowledge. I also certify That I am authorized to effect charges to the above card.

Amount to be charged: $_________________ U.S. Dollars

Includes freight charges &/or tax if applicable.

Year:________________  Make:__________________________ Model:_________________________

Description of the part:__________________________________________________________________

Salespersons name:_______________________________________________________