EFTA00522671.pdf

Laneventtur Credit Card Authorization ALL FIELDS MUST BE COMPLETED FOR CREDIT CARD TO BE PROCESSED: Please complete and fax to: (828) 438-9198 Dealer Name: LaneVenture Account Number: Cardholder Name as it Appears on Card: Street Address as it Appears on Card: City, State, Zip: Card Type: VISA MASTERCARD Credit Card Number: Expiration Date: (MM/YY) 3 Digit Security Code: By signing this form, you are giving Laneventure permission to charge the listed order(s) or invoice(s) to your credit card. You are also authorizing Laneventure to charge any applicable transportation costs, in addition to the order amount, to this card. Cardholder Signature: Date: REMITTANCE ADVICE (required): Invoice # Dollar Amount to Charge fAck H if Cash with Order) Total Amount to be Charged: EFTA00522671