MyRcMart.com Credit Card Authorization Form

A customer maybe requested to provide this form if the order is over a certain amount (eg. over USD300 included Shipping); to be delivered to the counties with high rate of parcels reported lost (eg. Italy, Indonesia, Malaysia, etc.) 1. Complete the form and fill out all billing and shipping information in the blanks below 2. Print the entire form and sign with the credit card holder's signature on the line indicated. 3. The following supporting documents are required: A photocopy of the front and back of the signed credit card. A photocopy of the CREDIT CARD BILLING STATEMENT, which can show clear the BILLING ADDRESS 4. Email this form with the supporting documentation in order to complete your order.: sales@myrcmart.com Shipping Address: Name: __________________________ Address 1: _____________________________________ Address 2: _____________________________________ City: __________________ Prov/State: _______ Postal Code: ________ Phone Number: ______________________ Billing Address (if different that above): Name: __________________________ Address 1: _____________________________________ Address 2: _____________________________________ City: __________________ Prov/State: _______ Postal Code: ________ Phone Number: ______________________ Credit Card Information: Credit Card Type (please circle one): Visa / Mastercard Credit card number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Expiration Date: __ __ / __ __ (MM/YY) CVV Number: __ __ __ __ (This is the 3 to 4 digit number on the back of the card, it is the last numbers in the signature area after the credit card number.) I authorize (___________________________________) to charge my credit card in the amount of ( USD ) / ( ___ ) _____________________ For Item(s): ____________________________________________________________________ Order Number: ____________________________ By signing this authorization form, I understand that the charge DO NOT include any duty and tax. I will be responsible for my local country duty and tax (if any), as well as Shipping Risk such as item(s) discarded by Custom and lost(if not insured). Card Holder Signature ____________________________ Date __ __ / __ __ / __ __ __ __ (DD/MM/YYYY)