Home Center, Inc.
Credit Card Authorization Form
Print out and fax to us at 708-636-1310
Cardholders Name
Address
City
State
Zip Code
Home Phone
(
)
Work Phone
(
)
Cell Phone/Pager
(
)
Type of Card
Card Number
Expiration Date
CVC#
ONE
MUST BE
CHECKED
Phone Order Authorization
Authorization for
(name of person) to use card
ONE
MUST BE
CHECKED
Single Purchase Only, Date of Purchase
Numerous Purchases
Signature
MUST ALSO FAX A LEGIBLE COPY OF YOUR DRIVER'S LICENSE.
NO EXCEPTIONS
FAX TO:
ALSIP
Fax (708) 636-1310
11150 S. Cicero Ave
Phone (708) 636-3500
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