CREDIT CARD AUTHORIZATION FORM:

We sometimes require, at our own discretion, a customer to fill out and fax a manual authorization form.  We do this when an item has a high value, if the item needs to be shipped anywhere other than the customers billing address, if an international credit card is used or if simply the customer requests it.  In these instances, we need to obtain your written authorization. 

If you are going to ship to an alternate address, you need to call the bank that issued your credit card and add the second address as an authorized alternate shipping address.  The phone number of the bank that issued your credit card is usually found on the back of your card.

Please follow instructions below to complete our Credit Card Authorization Form.



Instructions

  1. Complete the form online OR print the form by clicking “PRINT FORM” and complete the blanks legibly with a BLACK pen.
  2. Sign at the bottom.  Signature must match the signature on the credit card.
  3. Include a photocopy of the front and back of the signed credit card, which you will be using.
  4. FAX (1-514-392-1255) OR scan and email (info@mendax.com) the completed form and the photocopies of the credit card to complete your order.
 

 

Credit Card Authorization Form

  I, ,(name as it appears on Credit card)                 hereby authorize Mendax Microsystems Inc.  to charge my credit card account in the amount of $   with / add shipping    USD CAD

  VISA

MasterCard American Express
Name of Bank that issued your credit card: 
Bank Telephone Number:  
Credit Card Number:  

Expiration Date:  /            VID Code:  What is it?

Credit Card Billing Address:

Street: 
               
City:     

State:    
Zip Code:  -

Country: (if not US)  

Telephone:  () -

Requested Shipping Address:

Street: 
               
City:     
State:   

Zip Code:  -

Country: (if not US)  

Telephone:  () -

As the credit card holder, I hereby authorize receipt of merchandise at the shipping address above.
__________________________________ ____/____/______
Cardholder's Signature Date

(Optional) As the credit card holder, I also authorize Mendax Microsystems Inc.  to charge my credit card for future purchases verbally approved by me.
     Authorization Valid Until: /         Initials Here:

Your completion of this authorization form helps us to protect you, our valued customers, from credit card fraud.  All information entered on this form will be kept strictly confidential by Computer Online.

Fax Back
1-514-392-1255