Create-A-Book

Authorization for Visa/Mastercard/American Express/Discover

To make purchases with your charge card, either by phone or by email, please print this form on your printer, complete the form and mail it to Create-A-Book or fax it

Create-A-Book
77 N. Magneto Drive
Pueblo West, CO 81007

FAX 719-647-1767

I hereby authorize Create-A-Book to charge my charge account for invoices for software, books and supplies, and to retain this authorization in my files to be used on future orders until cancelled in writing by me.  

Dealer Name   _____________________________

Dealer Number    ___________________________

Dealer's Email Address ______________________

Name on card ______________________________

Address __________________________________

__________________________________________

__________________________________________

Phone number  _____________________________

Card Number ______________________________

Expiration Date ____________________________

Signed ___________________________________ Date_______________