Shipping Authorization form

Serenity Designs
AmysLingerie.com
6034 Chester Ave Suite 104B
Jacksonville FL 32217

Fax # 928.585.2136

This document is for your protection and ours. If you do not wish to complete this from, you have the option of simply contacting your bank and having them list a secondary address on your account. We can then verify the information over the phone with your bank. We appreciate your cooperation in preventing online credit card fraud and for helping to make the web a safer place to shop. Failure to adhere to our policy will result in the delay of your order and automatic shipment to the billing address.

Order #:_______________________________________________

Cardholder Name:________________________________________

Billing Address:__________________________________________
(address on file with credit card company)

Phone Number:__________________________________________

E-mail Address:__________________________________________

If Shipping to Alternate Address:

By signing this form, I certify that I am the true cardholder and hereby authorize AmysLingerie.com c/o Serenity Designs to bill the following credit card for merchandise cost and applicable shipping charges in the amount of $____________. I further authorize shipment to be made to an address other than my billing address (if applicable). Signing this form also indicates that I have read and understand the terms of sale, including shipping, delivery and return policies as outlined on the web site.

Visa______ MasterCard______ American Express______ Discover Card______
(please check one)

*Card Issuing Bank's phone number:____________________________
(for verification purposes - printed on back of card or credit card statement)

Card Number ______________________________Expiration _____/_____
Cardholder Signature: x___________________________________ Date: __________

PLACE FRONT OF                                         PLACE BACK OF
CREDIT CARD HERE                                CREDIT CARD HERE
    Must be light and legible                                Must be light and legible