Royal Japan Imports Credit Card Verification Form

Credit Card Verification Form

www.royaljapanimports.com		Date: ______________________
Royal Japan Used Imports, Inc.
126-45D Willets Point Blvd	Tel: 718-779-8729
Corona NY 11368	Fax: 718-779-1741

Please Fax form to us. Purchase will not be shipped until this form is Completed & Verified.

Company Name:

___________________________________________

Address:

___________________________________________

City, State & Zip:

___________________________________________

Email Address:

___________________________________________

Phone #:

_______________________

Address:

___________________________________________

City, State & Zip:

___________________________________________

Attention to:

___________________________________________

Phone #:

_______________________

Parts:

___________________________________________

Price:

_____________________

Shipping:

_____________________

Total:

_____________________

We Accept All Major Credit Cards

Card Holders Name as it on Credit Card: _____________________________________________

Billing Address:

___________________________________________

City, State & Zip:

___________________________________________

Credit Card#

__________________________

Expiration Date:

______ / ______ /

V-Code:

__________________________

I hereby authorize Royal Japan Used Imports Inc. To charge the order as described
my credit card, as noted above. I understand and agree to the sales policy and warranty.

Card Holder's Signature: _____________________

Date: _________________________

Note: Please fax us a copy of your license and both sides of your card.