051117/863-060330/1011-080512/1742
(this is not your Order Number: this is just a 'hit' counter, for us to keep track of 'visits' to this page)
(Print this page, fill in with your credit card details, your SSN / EIN details, and fax it back to us. Hit 'Back' to return to web site. Please click here for the need for SSN / EIN details)
CanadianMoose.com, Inc.
622 Schubert Place NW, Calgary, Alberta T3L
1X4 Canada
www.CanadianMoose.com
Calgary & surrounding area:
Telephone: 403.547 - 3118
Fax: 403.547 - 2564
Remainder of Canada and the U.S.A.: Telephone (toll free):
1.877.547 - 3118
Fax (toll free): 1.877.666 - 7397 (1.877.MOOSE97)
International:
Telephone: (Country code 001) 403.547 -
3118
Fax: (Country code 001) 403.547 - 2564
CREDIT CARD AUTHORIZATION - SSN / EIN FORM (please print)
Today's Date (YYYY/MM/DD): ______/____/____
Name: ___________________________________________________
Telephone (home): ___________________ e.g. 403.555-1212
Telephone (work): ___________________ e.g. 403.555-1212 ext.123
E-mail: __________________________________
Company Name: ___________________________________________
Product Ordered: ___________________________________________
(just a short description so we can match this form up
with your order; don't worry about re-writing the Product #s here)
When did you place the order? (YYYY/MM/DD): ______/____/____
SSN / EIN: [ ]-[ ]-[ ]
Please indicate the credit card to be used: ___VISA ___MasterCard ___American Express
Credit Card # (CC#):
[ ]-[
]-[ ]-[ ]
Exp Date (MM/YY): [ ]-[ ]
SID #: [ ]
(PLEASE PRINT CREDIT CARD NUMBERS CLEARLY)
Name on Credit Card: ___________________________________
Signature: ______________________________
(credit card order cannot be processed without this)
051117/863-060330/1011-080512/1742
(this is not your Order Number: this is just a 'hit' counter, for us to keep
track of 'visits' to this page)