Auction Gallery of the Palm Beaches, Inc.
1609 So. Dixie Highway, Suite 5, West Palm Beach, FL 33401
Credit Card Authorization Form
Billing Street Address:
Direct Telephone: ( )
I hereby affirm that I am the owner of the below referenced credit card and
that my name is listed on the front of the credit card.
I hereby authorize Auction Gallery of the Palm Beaches to charge my credit
card (listed below)
in the amount of $__________________ for payment of goods purchased at
Account Holder Signature
CREDIT CARD INFORMATION
Credit Card Type: □ MasterCard □ Visa □ American Express □ Discover
______ Expiration Year: _____
Cardholder Signature X