GREAT SCOT INTERNATIONAL INC CHARLOTTE NC AUTHORIZATION FOR PAYMENT BY CREDIT CARD Customer/Store Name City/State/Zip Credit Card Type
VISA
MC
DISCOVER
Account Number CVV or Code Name as it appears on Card (Please print) Address as it appears on Card Statement Expiration Date
/
Authorized Users on card Phone Number
(
)
Email address Hand Signature of Card Holder Position Note: Signing this form gives Great Scot International the authority to bill the credit card listed above for products purchased by authorized users
Please fax this form to (704) 973 9735 or email to sales@greatscotintl.com Questions on this form ? Please call (877) 359-8369
AMEX