GOLD
CHANCE TRADING USA, LLC
CREDIT CARD CHARGE AUTHORIZATION FORM
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| Instructions
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Please
print out this form, fill in the blanks and sign it. With a copy of
your credit card (front and back) and a picture ID, fax to 212-868-9661.
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APPLICANT’S
INFORMATION
Please enter the name of the person and the company who/which
placed the order |
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| ____________________ |
____________________ |
____________________ |
| LAST
NAME |
FIRST
NAME |
MIDDLE
NAME |
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________________________________________ |
| COMPANY
NAME |
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CREDIT
CARD INFORMATION
Please enter the credit card billing address and name as it appears
on credit card |
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| ____________________________________________ |
_____________________________ |
| NAME
AS IT APPEARS ON CREDIT CARD |
TELEPHONE
NUMBER |
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| _____________________________________________ |
_____________________ |
| STREET
ADDRESS |
APT/UNIT/PO
BOX |
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| _____________________ |
_____________________ |
_____________________ |
| CITY
|
STATE |
ZIP
CODE |
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| _________________________________ |
__________/___________ |
| CREDIT
CARD NUMBER |
EXPIRATION
DATE (Month/Year) |
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| ______________________________
CID (Card ID): |
Last
3 digit number on the back of your card
or 4-digit number on front of AMEX |
| CID
(Card ID) |
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| I,
__________________________________ (full name as appears on the credit
card), hereby authorize Gold Chance Trading USA, LLC to charge my
credit card in the amount of $_________, for the order placed on ___/___/______
. |
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| ____________________________ |
____________________________ |
| SIGNATURE |
DATE
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|
(OPTIONAL)
As the credit card holder, I also authorize Gold Chance Trading
USA, LLC to charge my credit card for the future purchases verbally
approved by me.
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| ______________________
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| AUTHORIZATION
VALID UNTIL |
INITIALS |
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| Gold Chance
Trading USA, LLC will keep all information entered on this form strictly
confidential. |