PLANT CITY AUTO SALVAGE

4303 FL 574, Plant City, FL 33563 | Fax: (813) 719-8249

4102 James L. Redman Pkwy, Plant City, FL 33567 | Fax: (813) 756-5874
pcas1@plantcityautosalvage.com

Credit Card Authorization Form

Please complete all fields.
Credit Card Information
Card Type: ☐ MasterCard ☐ VISA ☐ Discover ☐ AMEX

Cardholder Name (as shown on card):

Card Number:

Expiration Date (mm/yy):

Card Verification Code (CVC):

Three digits often located on the back of the credit card. For AMEX, the four digits is located on the front of the credit card.

Cardholder Billing Address:

Cardholder City, State, Zip Code:

I, , do hereby authorize Plant City Auto Salvage

to charge my credit card above for payment in full for agreed upon purchases in the
amount of $ 60.00 for 1999 explorer 4.0
ECM .
I certify that I am the authorized user of this credit card and that I will not dispute the
payment with my credit card company. I fully accept and abide by Plant City Auto
Salvage terms and conditions in regards to warranty, refunds, and/or exchanges.

________________________________ _________________________
Customer Signature Date

Cardholder Phone Number: (_________) _________________________