BiX Credit Card Order Authorization Form

Please Print All Information Clearly

Order #:_________________________ Total Amount: $_________________________ 

 Credit Card #:  ___________________________ Exp. Date: _____/_____

Credit Card Ownerˇ¦s Info

Name:______________________________________________

Street Address: __________________________________________

City:___________________________ State:_______ Zip:___________ 

Country:_____________________ Telephone #:_________________________

I hereby certify that I am the above credit card owner and authorize

BiX International, Inc. (DBA BiX Computers) to debit my credit card

for the amount of US$ ________________

and I authorize BiX Computers ship the order to following address:

Name:______________________________________________

Street Address: __________________________________________

City:___________________________ State:________ Zip:___________ 

Country:_____________________Telephone #:_________________________

 

Signature:_____________________________   Date:_________________