Capital Original Wheels
Credit Card Authorization Form
Card Holder Information (All fields are Require) 800-463-7467 FAX 323-321-9192 sales@capiatalwheels.com

Name:

Billing Address:
Street-
 
City-
State/ Zip/

Order ship to address:

Street-

City-
State/ Zip/
Note: If this address differs from billing address, card holder MUST contact issuing bank and add this to 'Ship To' address to their account, prior to order being processed.
Home Phome -- Work Phome --
e-mail Address

Visa Master Card, and Discover Card ONLY
Card Type
Issuing Bank:
Card Number: - - - Expire: Bank Phome - -
Security Code (Last 3 Digits on back of Card)

I hereby authorize Capital Original Wheels to process the above credit card for full payment of the telephone / internet order placed with Capital Sales Representative (Name) on (Date)
Order Amount Invoice Number

1. I understand that all charges related to this order, including freight, as well as a core charge(please read note below), will be processed on the above designated card. In the event tha tcharges cannot be processed on the above card, I agree to be personally responsible for payment of these charges via guarantee funds to Capital Original Wheels upon demand.
2.Core Charges: I understand that core charges processed on my credit card will be creditedin full upon receipt of my "exchange cores" provided the cores received from me are in goodcondition, spin true, and are sellable wheels. My core credit amount may be reduced by anyrepairs needed (starting at $65), or by a chrome stripping fee ($30 per wheel) in the event thatI return chrome cores.
You will be contacted by your sales representative upon receipt of your cores should any repairs,or chrome stripping be required.
I further understand that Capital Original Wheels does not pay for freight for the return of product.This include exchange cores, as well as warranty returns.
_______________________________________ ________________________
Credit Card Holder Signature (print and sign) Date Signed
Description: