Please print, complete, and return the Credit Card Authorization form with your AUTHORIZED SIGNATURE, so that we may process your order. Please note, you may fill out the form, scan it, and send it back by e-mail as a *.pdf or*.jpg attachment or you may fax it to us if your card has raised numbers.

FRATERNAL REGALIA
by University Apparel, Inc.
2501 Mount Holly Rd #262
Burlington, NJ 08016
phone: 609-871-3601 ~ fax: 609-871-3602
http://www.fraternalregalia.com

Credit Card Authorization Form

Customer Name:_________________________ 

Billing Address:_______________________

City/State/Zip:__________________________

Home Phone: ______________________ Work/School Phone: ___________________

E-Mail address: _________________________@______________


SHIP TO Name (If different from above):_________________________ 

SHIP TO Address (If different from above):_______________________

SHIP TO City/State/Zip:__________________________

Note: Shipping addresses must be COMPLETE. There will be a minimum fee of $15.00 to CHANGE  invalid shipping addresses, either prior to shipping or in-transit.

INVOICE #_________________ (if applicable)

Credit Card (circle one):     MC     VISA     DISCOVER

Please impress/copy/scan credit card in the space below:








To make an impression of cards with raised numbers, place card under form, numbers facing up. Hold card in place and rub pencil point across the block, using moderate pressure. Please ensure that all information, including cardholder name is completely traced above.

Card #: ___________________________________ expiration date: _______

Cardholder Name: ___________________________  3 Verification Number*: ______

Cardholder Signature: ___________________________ Date: _____________

*For your safety and security, we now require that you enter your credit card's verification number. For MasterCard, Visa or Novus (Discover) cards, the verification number is a 3-digit number printed on the back of your card. It appears after and to the right of your card number. (see sample below)

 

This is to advise that University Apparel is authorized to accept orders from me by e-mail, telephone, or fax, charge the cost of such orders to my credit card account, and to ship the merchandise to the address that I provide. By signing this document, I accept all responsibility for these transactions and ensure full payment to the merchant. I will inform you immediately if use of this card is no longer valid. 

Please print, complete, and return the Credit Card Authorization form with your AUTHORIZED SIGNATURE, so that we may process your order. Please note, you may fill out the form, scan it, and send it back by e-mail as a *.pdf or*.jpg attachment or you may fax it to us if your card has raised numbers.