Credit Card Authorization Form

Complete this form to make a Credit Card Payment or Place A Special Order

First Name*

Last Name*

Business Name (Optional)

Email*

Billing Address Cardholder*

City*

State (2 Letter Abbreviation)*

Zip Code*

Phone Number Associated with Card*

Enter Entire Credit Card Number*

Card Type*

CVC Code*

Expiration *

P.O. or ID number (Optional)

Amount Authorized to Charge**

Agree to Terms Stated Below (Enter Initials)

Signature

Date

Shipping Address

Business Name (Ship To)

Ship to Attn

Address (Shipping)

City (Shipping Address)

State (2 Letters)

Zip Code (Shipping)

Year*

Make (Ford, GM, BMW, Toyota, etc)*

Model*

Part Requested*

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TERMS

Please be aware, by submitting this form you are authorizing Acme Auto Parts to charge the credit card submitted on this form for the amount specified. This transaction is non-refundable, defective merchandise will be replaced if returned within 30 days. Merchandise must be in the exact same condition as purchased. We are not responsible for any damage caused while merchandise is in your possession. We are not responsible for any additional costs incurred in the installation of this merchandise, including labor. Freight is non-refundable.