Charge To: Visa __  M/C __ Discover __ Amex __
Card # _____-_____-_____-_____

CVV2: Last 3 Digits on Back of Card: _____
Exp. Date ___/___
Name (as printed on card) ___________________

Signature:______________________

Order Date: ___/___/___

By signing this Credit Card Authorization form, I authorize APS Cellular, Inc. to debit and/or credit the card number listed below for invoices approved by myself or the authorized users listed. By signing this order you acknowledge that you are the authorized credit card holder, have read & understand our sales terms & policies and agree to be bound by these conditions of sale. All sales are final. I am also authorizing shipment to the above alternate shipping address if different from actual credit card billing address. If for any reason the charge is denied,stopped,reversed, revoked or other the applicant agrees to pay all and or any collection costs incurred to collect the balance, including, but not limited to court costs, collection fees, office fee's and attorney fees of not less than 33% of the unpaid principal and interest.

Along with this form, please supply a clear copy of the credit card front and back and a clear copy of your state drivers license. Set Copier to Text/Photo Mode, Enlarge Copies by (2) Times. Copies must be clear & form must be legible. All information is kept confidential and not shared.