PLEASE FAX BACK TO US AT (305) 599-6148

We need a copy of your ID Card and copy of

the credit card both front and back. You can scan these & email to sales@allveterinarysupply.com

CREDIT CARD AUTHORIZATION FORM

Billing Information:  (Same as Credit Card Billing Info)

Name of Cardholder:

Billing Address:

City, State, Zip

Ph:

Fax:

Credit Card Number:

Expiration Date (Month/Year):

Payment form:

(Choose One)

Visa

Mastercard

Discover

American Express

Fill in:

(CV Code):

Mastercard/Visa/ Discover:

(Last 3 Numbers on back of card):

Amex:

( 4 small numbers on front of card on right):

I, _____________________________, authorize All Veterinary Supply, Inc. to charge my

credit card referenced above to purchase the following items:

Quantity

Description of product

Price $

Total $

Freight $ Amount

Total Amount $

Cardholder Signature:

Name Print:

Date