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MILLERS True Value / Go Karts R us 115 N. Exchange St. Geneva, NY 14456 |
Name on Card:_____________________________________________________________________________ Credit Card Number:_______________________________________Exp:__________Security CVV2:_______ Credit Card Type: (circle one) Visa | Master Card | Discover | Am/Ex | Debit Card w/ Visa or M/C logo Credit Card Billing Address:___________________________________________________________________ City:___________________________________________State/Prov:___________________Zip:____________ Phone# (associated w/ Card):______________________________(other optional):________________________ Cardholders Signature:__________________________________________________ Date:_______________ (By signing you are authorizing us to ship to the below address billed to your above Credit Card) |
Delivery Persons Name:______________________________________________________________________ Delivery Persons Address:_______________________________________________(PO Box for approved shipments) Delivery Persons City:____________________________________State/Prov:_____________Zip:___________ Delivery Persons Phone#:_______________________________(other optional):___________________________ |
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| Copy this form with your Credit Card & Driver License in above areas, then send completed form to above address or fax |