CPI LUXURY GROUP
CPI Center
10220 Norris Ave.
Pacoima, CA 91331

Phone:  (800) 749-9888      Fax:  (818) 249-4777

CREDIT CARD AUTHORIZATION
Please fill out form, print and fax to (818) 249-9596

DATE: //
Invoice # / Sales Order#:

Master Card  Visa

Amount Authorizing:

  Amount:
$

  Initial:

Company Name:
Credit Card Holder:
Credit Card Number:
Expiration Date:
Phone Number:      Fax Number:
Card Holder Signature:

Date: //

Statement Billing Address:
(office use)
Authorization Number:
 

www.cpilg.com
 
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