ORDER FORM

Silkies for sale

Online appointment

Newsletter Signup

Silkies RSS

Silkies Rss

Home

Chicken Breeds

ORDER FORM

One Time Credit Card Payment Authorization Form

Sign and complete this form to authorize Amber Waves to make a one time debit to your credit card listed below.

By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission may apply to a single or multiple transactions but does not provide authorization for any additional unrelated debits or credits to your account.

Please complete the information below:

I (full name) authorize Amber Waves to charge my credit card account on or after (date)

This Payment is for:

Poultry Cost

at
_{(number of birds)} _{(cost each)}

_{(total poultry cost)}

Shipping Cost

_{(include Express Mail Postage,fruit and new shipping box)}

_{(total shipping cost)}

DNA Test

at $25.00 each
_{(number of birds)}

_{(total shipping cost)}

Total $

Billing Address:

Phone:

City, State, Zip:

Email:

Account Type

Visa MasterCard AMEX Discover

Cardholder Name:

Account Number:

Expiration Date:

CVV2:

SIGNATURE:

DATE:

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

Silkies for sale

Main Menu

Online appointment

Who's Online

Silkies RSS