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Auction Gallery of the Palm Beaches, Inc.
1609 So. Dixie Highway, Suite 5, West Palm Beach, FL 33401

Credit Card Authorization Form

CARDHOLDER INFORMATION
Name:
Billing Street Address:
City:

State:

Country:

Postal Code:
Email

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
auction.
_________________________________
Account Holder Signature

CREDIT CARD INFORMATION
Credit Card Type: □ MasterCard □ Visa □ American Express □ Discover
Card
Number: ________________________________________________________________
Expiration Month:
____________

______ Expiration Year: _____

Cardholder Signature X
Security Code:

Security Code:
Date /

/

www.agopb.com