QBilliards Credit Card Authorization Form

CREDIT CARD AUTHORIZATION FORM

ebay item # ebay member name (if applicable)

I, (full name), hereby authorize QBilliards

to charge my credit card in the amount of $ (Canadian Dollars)
	CLICK HERE for a currency converter.

Credit Card Details :

Card Type Card Number Exp. Date /

Street :		mm / yy


City :	State: Zip Code :

Country :	United States Of America Canada
	email address:
	Telephone: ( ) - Fax: ( ) - (if applicable)

As the credit card holder, I hereby authorise charging of this card

Cardholder's Signature

Today's Date is:

Comments

QBilliards Contact Details:
Fax: (250) 479 6735, Tel: 1 866 816 1128
P.O. Box 41036, 5134 Cordova Bay,
Victoria, British Columbia, V8Y 3C8, Canada.