1902 McGaw Avenue

Irvine, CA 92614
P: 949.567.9000
F: 949.567.9010
www.cp-carrillo.com

Credit Card Authorization

Use your Visa or MasterCard to purchase from CP-CARRILLO.

Please complete and sign this authorization and mail or fax it to us.

I authorize CP-CARRILLO to charge my purchase(s) to my credit card listed below.

MOHAMMED ALBASTI
Name of Company: __________________________________
MOTOR SPORT CO. Customer #:_____________________

Name of Cardholder: _______________________________________________________________

MOTOR SPORT

BIRKAT AL-AWAMER STREET #3023 BUILDING #58 ZONE #91 DOHA QATAR
Credit Card Billing Address: Street: _________________________________________________
QATAR 22732
City: __________________________
AL-WAKHRA
State: ______ ZIP _________
+974 4414 8441 support@motorsportco.qa, sales@motorsportco.qa
Telephone: _______________________________ E-Mail: __________________________________

Charge to: MasterCard Visa

QA51QNBA000000000032003424001
Account #: _______________________________ Expires: ____/___
10 27

Three-Digit Security Code on back of Credit Card: ___________

368

Your Credit card information will be kept on file for future purchases, unless you notify us otherwise
(All information provided will remain confidential)

__________________________________
Cardholder Signature
Submit Form Via Email

Please Return this Authorization to:

1902 McGaw Avenue

Irvine, CA 92614 USA
F: 949.567.9010 Accounting Fax: 949.783.3908
Attention: Accounts Receivable

For Office Use Only:

Date Received: _________ Received By: _________ Customer Number: _________

Form 72-60, Rev. D