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 #215 27353 58th Crescent, B.C. Canada V4W 3W7
Telephone: (604) 607 - 1111 ~ Fax: (604) 607 - 1107
E-mail: sales@iplayco.com Web Site: www.iplayco.com

CREDIT CARD TRANSACTION AUTHORIZATION FORM

Customer Name: _____________________________________________________________________________

Shipping Address: ____________________________________________________________________________

City: __________________________________________ State/Prov: ___________________________________

Country: ____________________________________ Zip/Postal Code: _________________________________

Phone Number: ______________________________ Fax Number: ____________________________________

Date: ______________________________________ Email address: ___________________________________

Order Detail:
Item# Description Quantity Unit Total
Price

Shipping
Taxes
TOTAL CHARGE

Credit card information: Please fill in and return to fax number: 604-607-1107

VISA ( ) MASTERCARD ( ) Funds: Canadian ( ) U.S. ( )

Name on the card: ________________________________________________________

Credit Card Number: ______________________________________________________

Expire Date: ___________________________________________________________

Billing Address for the card: _______________________________________________

City/State/Zip Code: _______________________________________________

By signing below, I authorize International Play Company Inc. to debit this credit card for the order specified above.

Signature: _______________________________________ Date: _______________________

FOR IPC USE ONLY:

Authorization Number: ______________________________________ Date: ____________________________