| The Sunshine Lighter Co. |
| 600 Oak St # 4 , Port Orange FL 32127 |
| (386) 322-1300- FAX: (386) 788-0609 |
| Date::- - - - - - - - - - |
| From::- - - - - - - - - - - - |
| RE: Credit Card Purchase |
 |
|
| Thank you for placing your order with us. To protect you from credit card fraud we require a copy of your signature to process your order. |
| I __________________________________________ Hereby authorize The Sunshine Lighter Co. |
| Type: - - - - - - - - - - - |
| Account #: - - - - - - - - - - - - - - - - - - - - - |
| Exp. Date: - - - - - - - - - - - - - - - |
| Code: (The last 3 digits located on the back of the card) |
| Credit Card Info |
| Credit Card Billing Address: |
| Name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
| Street Adress - - - - - - - - - - - - - - - - - - - - - - - - |
| Company name & Address: |
| Shipping Address: |
| Date :_____________ |
| Signature:__________________ |
| Name on card: - - - - - - - - - - - - - - - |
| City,ST,Zip Code - - - - - - - - - - - - - - - - - - - - - - |
| to charge my credit card for the purchase in the amount or up to (Maximum) $- - - - - - - - - - |
| Amount (Please type)- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
| Phone - - - - - - - - - - - - - - - - - - - - - - - - - |
| Phone: - - - - - - - - - - - - - - - - - - - |
| - - - - - - - - - - - - - - - - - - - - - - - - |
| Name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
| Street Adress - - - - - - - - - - - - - - - - - - - - - - - - |
| City,ST,Zip Code - - - - - - - - - - - - - - - - - - - - - - |
| Phone - - - - - - - - - - - - - - - - - - - - - - - - - |
| - - - - - - - - - - - - - - - - - - - - - - - - |
| Name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
| Street Adress - - - - - - - - - - - - - - - - - - - - - - - - |
| City,ST,Zip Code - - - - - - - - - - - - - - - - - - - - - - |
| Phone - - - - - - - - - - - - - - - - - - - - - - - - - |
| - - - - - - - - - - - - - - - - - - - - - - - - |