I, the designated cardholder of the above listed card, authorize MicroAge to charge the amount of $______ to the above l
CREDIT CARD AUTHORIZATION FORM
Card Holder Information
Card Type (check one): MasterCard American Express Name (as appears on card): ____________________________________ Card Number:
_________________________________________
Card Expiry Date: ___ ___/___ ___ Daytime Phone Number: (_____) _________________ E-Mail Address (for copy invoice and receipt): ____________________________________
Authorization
I, the designated cardholder of the above listed card, authorize MicroAge to charge the amount of $_______ to the above listed credit card. Description: ________________________________________________________________ Signature of Cardholder: ______________________________ Date: _________________
Please complete this form and email back to
[email protected]
1060 Winnipeg Street, Regina, Saskatchewan S4R 8P8 Tel.: 306-525-0537
