close window to exit
<table>
<caption><center><h2>Credit Card Authorization Of Charge</h2><br>Use Only If Requested</center></caption>

<tr>
<td>
Instructions: Print this form. Photo copy driver's license and front/back of credit card, attach to form and fax to Dave's Web
Shop at 479.997.1918 (24 hours fax).
<p>
I am (print name) ______________________________ and hereby give authorization
for Dave's Web Shop to charge my purchase to the card below. I have read and
understand the store policies located on the web site order pages and at the web sites of
Dave Fant Company Of Arkansas Inc. A copy of the policy is located at the web site
address of http://www.daveswebshop.com/policy.shtml. I agree to the store policies concerning
my order. 
</td>
</tr>
</table>
<p>
<center>
<table>
<table border="1" cellspacing="0" cellpadding="0">
<caption><h3>My Driver's License</h3></caption>
<tr>
<td>Attach legible copy of Driver's License here<br>
Attach legible copy of Driver's License here<br>
Attach legible copy of Driver's License here<br>
Attach legible copy of Driver's License here<br>
Attach legible copy of Driver's License here<br>
Attach legible copy of Driver's License here<br>
Attach legible copy of Driver's License here<br>
Attach legible copy of Driver's License here<br>


</td>


</tr>
</table>


<p>
<p>
<p>


<table>
<table border="1" cellspacing="0" cellpadding="0">
<td>


<caption><h3>My Credit Card Information</h3></caption>
<tr>
<td>
Attach legible copy of card front here&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Attach legible copy of card back here<br>
Attach legible copy of card front here&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Attach legible copy of card back here<br>
Attach legible copy of card front here&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Attach legible copy of card back here<br>
Attach legible copy of card front here&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Attach legible copy of card back here<br>
Attach legible copy of card front here&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Attach legible copy of card back here<br>
Attach legible copy of card front here&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Attach legible copy of card back here<br>
Attach legible copy of card front here&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Attach legible copy of card back here<br>
Attach legible copy of card front here&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Attach legible copy of card back here<br>
Attach legible copy of card front here&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Attach legible copy of card back here<br>
Attach legible copy of card front here&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Attach legible copy of card back here<br>





</td>



</tr>
</table>



<p>
<table>
<table border="0" cellspacing="0" cellpadding="0">
<caption><h3>My Information</h3></caption>
<tr>
<td>
<ul>
<li>
<li>Name_________________________Billing Address_________________________
<li>&nbsp;
<li>City_________________________ State_______ Zipcode_______
<li>&nbsp;
<li>Telephone_________________________
<li>&nbsp;
<li>&nbsp;
<li>Card Type - Visa - Mastercard - American Express - Discover
<li>&nbsp;
<li>Card Number_________________________ Expiration Date __________
<li>&nbsp;
<li>Security Code* from back of card (front for Amex)__________
<li>
<li>Type of equipment ordered ___________________________________________
<li>
<li>Signature_____________________________________
<li>&nbsp;
<li>Date___________________
</td>
</tr>
</table>
*3 digit security code is located on the back after the card number. 4 digits on front for Amex
<p>
<b>Dave's Web Shop - Telephone 479-997-2230 - 24 Hour Fax Line 479-997-1918</b>