MILLERS True Value 115 N. Exchange St. Geneva, NY 14456 FAX# 315.789.6963 
This Form (must be Faxed or Mailed

Step 1: (Your Credit Card Billing Info)

Name on Card:_____________________________________________________________________

Credit Card Number:__________________________________________________Exp____________

Credit Card Type: (circle one) Visa | Master Card | Discover | Debit Card

Complete Billing Address:_____________________________________________________________

Billing City:____________________________________________State:___________Zip___________

Billing Phone Number (home):______________________(work/cell):___________________________

Cardholders Signature:_______________________________________________ Date____________
(By signing you are authorizing us to ship to the below address billed to your above Credit Card)

Step 2: (Your Shipping Address)

Delivery Persons Full Name:__________________________________________________________

Complete Delivery Address:________________________________________________(NO PO Boxes)

Delivery City:_________________________________________State:___________Zip___________
Delivery Phone Number:_____________________________(other):___________________________

Note: We will authenticate this information, any incorrect information will void this purchase, and may further implicate punishable laws for mis-use or false information. Credit Card fraud is a felony and we will pursueit to the fullest extent of the law.

Step 3: (Hardcopy) 
Place your..

Credit Card

HERE		 Place your..

Drivers License

HERE
Copy this form with your Credit Card & Driver License in above areas, then send completed form to above address or fax