Dejay Products

Credit Card Authorization Form

Please fill out and fax or email back to

Dejay Products 206-784-9109fax or

Email to dejaygold@dejaygold.com

Or contact us directly via phone at 206-784-8200phone

Cardholder Name:   ___________________  Signature:  _______________

Address:           ______________________________________________

                          ______________________________________________

Credit Card Type:
                        _____ VISA     _____ MASTERCARD    ___AMEX ___DISCOVER

Credit Card Number:
                                    ________ - ________ - ________ - ________
Expiration Date:
                                    ________ / ________

BillingAddress Street # and Zip Code:  ________  ___________

Card Identification Number (last 3 digits located on the back of the Visa/MC credit card):  ________  4 Digits for AMEX cards on the Front of AMEX Card

Amount Charged:  $  ________________ (USD)