The Shorty Store -- Get your awesome Shorty gear here!

You may use this form to email us your credit card information in order to make a payment on a purchase. You may NOT mail this form in. If you'd rather not fill out the online form, you may print this form out and then fax it to (323) 410-2272. Before faxing it, make sure your Order or Invoice number is written on the form somewhere so we can match it up with your order.

Do NOT try mailing us the credit card authorization form as it may cause a delay with your order.

Credit Cardholder Information
* = Required field

* Order Number:
This is the number on the invoice after you've placed your order.

* Name on credit card:

* Type of credit card:
Visa	Mastercard	Discover	AMEX	Other

If Other, please give us the credit card name:

* Type of account:
Business	Personal

Company name:

* Credit card number:

* Expiration date:

Billing address for credit card
* Street:	* City	* State	*Zip Code

* Phone number:
(XXX-XXX-XXXX)

Fax number:
(XXX-XXX-XXXX)

* E-mail address:

Authorized User of Credit Card
If different from above or you are not the owner of the card being used, please fill out the information below.

Name:
Company:
Phone number:
E-mail address:
Identification:
Relation to owner:
Type of charges:
Authorized amount:
Dates of charges:

Authorization of Card Use

I certify that I am the authorized holder and signer of the credit card referenced above.

I certify that all information above is complete and accurate.

I hereby authorize collection of payment for all charges as indicated above. Charges may not exceed the amount
listed above in the "AUTHORIZED AMOUNT" field. I understand this is only for up to this amount during the time
period of "DATES OF CHARGES" referenced above. If additional charges are going to be authorized a new form
will have to be completed.

* Cardholder name:
By entering your name in this field, this counts as a "digital signature" and you are agreeing with the authorization statements above.

* Date: