Site hosted by Angelfire.com: Build your free website today!

RapidDentureRepair
PO Box 301, East Stroudsburg, PA 18301
(570)350-0850
info@rapiddenturerepair.com

Home Up Feedback Contents Search

Order Forms


 

Up

CREDIT CARD AUTHORIZATION FORM

Please print this page (or download and print), fill in the required information and send with your denture. Or you can authorize over the phone after the denture is received. We can bill you through PayPal no credit card information required.

Microsoft Word Order Form | Adobe Reader PDF Order Form

 

Card Type (circle one) :   M/C   VISA   PayPal 

Card Number: __________________________________________________

Expiration Date: _______/_______/________

Card Holders Name:_____________________________________________
(exactly as it appears on the credit card)

Billing Address: _________________________________________________

City__________________________________________

State __________________ Zip __________________


Card Holder Phone Number: ( )________-______________

Charge Amount: ____$59 Denture repair ____$99 Duplicate denture (check service)

Authorization Code: _____________________ from the back of the card

Shipping Address (if different than billing address): 

_______________________________________________

City _______________________________ State _____________ Zip __________



Card Holder Signature:______________________________________________________


Card Holder Name (PRINT):__________________________________________________


Date Of Signature:_____________/_____________/_____________

 

 

 

 

Information Request Form

Select the items that apply, and then let us know how to contact you.

Send service literature
Send company literature
Have a salesperson contact me

Name
Title
Company
Address
E-mail
Phone

 

                      

 

Home ] Up ]

Send mail to JSTWebdesign with questions or comments about this web site.
Copyright 2010 RapidDentureRepair
Last modified: October 05, 2010