In order to protect card members from credit card fraud, we may ask you to verify your identity for orders shipping to alternate addresses. In such an event we will request that you a complete the credit card authorization form. Please print and fax the completed form to 1-201-934-7993. You must include a front & back copy of your credit card with this form.

 

Credit Card Authorization Form   

 

  I, , hereby authorize Hair Dynamics International, lace-front-wig.com  to charge my credit card account in the amount of $    ( with / add shipping)

  VISA/MasterCard

Discover

American Express

Credit Card Number: 

Expiration Date:  /            Security Code: 

Credit Card Billing Address:

Street: 
               
City:      State: 
Zip Code:  -

Country: (if not US)  

Telephone:  () -

Requested Shipping Address:

Street: 
               
City:      State: 
Zip Code:  -

Country: (if not US)  

Telephone:  () -

As the credit card holder, I hereby authorize receipt of merchandise at the shipping address above.

__________________________________

____/____/______

Cardholder's Signature

Date