| Please
PRINT this page and fill in the Authorization Form.
Sign it and either
Fax (808 875-1567) or mail it to us.
You may also call in your authorization,
800 981-5512. |
|
| Date
__________ |
|
Name ____________________________________________ |
| Address
__________________________________________ |
|
City
_________________________ State ____ Zip _______ |
|
|
VISA/MasterCard
____ American
Express ____
|
| Discover
Card ____ Diners Club ____ |
| Credit Card Number
__ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ |
| Expiration
Date __ __ / __ __ |
| Signature
_________________________________________ |
|
Ship
via (check one)
US Mail $25 (1-2 weeks delivery)
UPS 2nd Day $45 (2-3 days) |
