MILLERS True Value / Go Karts R us 115 N. Exchange St. Geneva, NY 14456
  This Form must be Faxed or Mailed FAX: 315.789.6963
Step 1: (PRINT CLEARLY Your Credit Card Billing Info)

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)

Step 2: (PRINT CLEARLY Your Ship-to Info)

Delivery Persons Name:______________________________________________________________________

Delivery Persons Address:_______________________________________________(PO Box for approved shipments)

Delivery Persons City:____________________________________State/Prov:_____________Zip:___________
Delivery Persons Phone#:_______________________________(other optional):___________________________

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