BROWNING PLEASE
PRINT CLEARLY
AUTO PARTS, INC.
3212 East Ceasar
Chavez
DATE:______________
Austin, Texas 78702
512-385-3461 SALES
REP:_______________
CREDIT CARD SALES SLIP/AUTHORIZATION
TYPE OF CREDIT CARD: ( CIRCLE ONE
) M/C VISA DISCOVER
AMEX
CREDIT CARD
NUMBER:___________________________________________
CARDHOLDERS
NAME:_____________________________________________
EXPIRATION DATE OF
CREDIT CARD: ______/______
MONTH YEAR
CARDHOLDERS
ADDRESS:__________________________________________
CITY:______________________
STATE:_____________ ZIP CODE:_________
PHONE NUMBER:
(______) ________-____________
SHIP TO
ADDRESS:_________________________________________________
CITY:______________________
STATE:_____________ ZIP CODE:_________
DRIVERS
LICENCE#________________________D.O.B. __________________
PARTS
REQUESTED:________________________________________________
____________________________________________________________________
Description of Charges: Payment for automobile parts
_________________________________________________________________________________
Subtotal_________________
Freight_______________Total___________________
I hereby authorize Browning Auto Parts, Inc., to apply
the total amount shown above to the above referenced credit card account.
______________________________
X___________________________________________
Please Print Your Name Please Sign Your Name
By my signature, I authorize the user of the card
identified on this item to pay the amount shown as total upon proper
presentation. I agree to pay such total ( together with any other charges due
thereon) subject to and in accordance with the agreement governing the use of
such card. I agree to hold harmless, Browning Auto Parts, Inc., from any and
all liability arising out of this authorization, including consequential
damages.
PLEASE RETURN TO FAX # 512-385-3719
TAX I.D. # ____________________________