Credit Card Authorization Form

Ordered From:

Select OneSean - CooksKipp - CooksJason - HeightsJim - HeightsChris - TraversMike - TraversJulie - WestwoodCarl - WestwoodOther

Card Holder Information/Billing Address

Name:

Street

City

State

Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code

Phone

Fax

Email

Type of Card Being Used:

Select OneVisaMasterCardDiscoverAmerican Express

Credit Card Number:

Expiration Date:

CVC Security Code:

Please Upload a Copy of Your Credit Card Being Used:

All Parts Are Quoted As Shipped to a Business

Residential Delivery will be Additional! $10.00 UPS Ground; $125.00 Truck Line

Part Requested

Year

Make

Part

Side/ID Number

Additional Information

Amount

Tax ID Number

Ship to: (if different than billing address)

Name:

c/o

Street

City

State

Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code

Please Upload a Copy of Your Driver's License or Federal ID:

I hereby authorize Cooks Auto Parts to charge my credit card for the above amount. I understand that this form with my signature is a binding agreement for this order. I understand this is not a receipt but an authorization. I understand my warranty will be stated on the actual receipt. Freight is NOT refundable for any reason

Cardholder's Signature