Embassy Vending
| Please fill in the order information below that correlates with the email receipt of the order you just placed at E-Vending.com. This form must be completed by the cardholder or it will not be valid and is subject to your order being cancelled. |
| Your E-Vending | Credit Card authorized | Credit Card | Amount Authorizing | Date | |
| Order # | to charge, (first & last 4 digits) | Exp. Date | E-Vending to Charge | ||
| __________ | _______xxxx-xxxx________ | ______ | ______________ | ______ |
My signature below hereby states that I have read the above
sales policies of
E-Vending and that I agree with them entirely and I hereby authorize E-Vending
to charge my credit card for the amount shown in the order information
above.
Customer's Printed Name____________________________
Today's Date_________________
Customers Signature_______________________________
revised 5-11-06