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Miami Li Inc. 5520 W. Flagler Street, Suite B, Miami, Florida 33134 USA Tel: 305-266-3991 Fax: 305-266-5348
Credit Card Authorization Form
Salon/Name____________________________________________________________________
Credit Card Billing Address________________________________________________________
City/State/Zip_________________________________________________________________
Tele_____________________ Fax____________________ E-Mail_______________________
Name as appears on Credit Card__________________________________________________
Credit Card No.______________________________________ Exp Date__________________
Include last 3 numbers that appear on the back of card above signature_________________
MC/ VS/ AMEX/ DISC (Please Circle) *If AMEX, include 4 digits above CC#.
Is credit card to be utilized for all orders? Yes or No (Please circle)
Comments_____________________________________________________________________ ________________________________________________________________________ It is the cardholder's responsibility, and she/he hereby agrees, to notify
Miami Li Inc., of any modifications to this request.
Amount of the order including freight charges: $____________ Date ordered: ___________
I authorize Miami Li Inc. to charge the above amount to my credit card and
I agree to pay according to my card issuer agreement.
Authorized Cardholder Name_________________________________________
Authorized Cardholder Signature_____________________________Date__________________
*Shipping Address_____________________________________________________________ *If different than billing address.
City/State/Zip_________________________________________________________________
PLEASE FAX TO 305-266-5348 |