GRAND PRAIRIE AUTO & TRUCK PARTS

3930 E JEFFERSON ST.

GRAND PRAIRIE, TX 75051

PHONE: 972-237-0405

FAX: 972-237-0348

AUTHORIZATION TO USE CREDIT CARD

Please complete the following form. Take extra care that all the information is legible and correct as this is our shipping information. Please circle one, we accept: VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS

Date:____________________________________________________________________________________

Cardholder Name:__________________________________________________________________________

Phone Number:____________________________________________________________________________

Billing Address:____________________________________________________________________________

____________________________________________________________________________

Work Number:_________________________________________Fax Number:_________________________

Credit Card number:________________________________________________________________________

Expiration date:________________________________________CCV code:___________________________

Customer Service phone number on back of card:_________________________________________________

Ship to:__________________________________________________________________________________

__________________________________________________________________________________

Attn:______________________________________________Phone number:___________________________

I hereby authorize Grand Prairie Auto & Truck Parts to charge the order described below to my credit card. My signature on this agreement is binding. I agree that if I refuse this shipment, all freight will be billed to my credit card. I understand that all parts are sold “as is”, unless otherwise noted on the invoice.

Detail of Charges Part Description

Parts $____________________________

Core $____________________________

Freight $___________________________

Tax $____________________________

Total $____________________________

Please be aware that returned parts may be subject to a 15% restocking fee.

Cardholder Signature: ______________________________________________________________________