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INTERNATIONAL INC.
1220 SPRING GARDEN STREET PHILADELPHIA, PA. 19123-3293 FAX: 1-215-922-0970
FOR PAYMENT BY MASTERCARD OR VISA CREDIT CARD or MASTERCARD OR VISA DEBIT CARD:
PLEASE FILL OUT THIS PAGE BY COMPLETING ALL BLANKS, INCLUDING A RUBBING OF YOUR CARD, AND SEND IT WITH YOUR ORDER FORM.
CARDHOLDER NAME ON CARD:__________________________________DRIVER'S LIC: ST____#___________________
STATEMENT MAILING ADDR:________________________________________________TEL#(____)__________________
CITY:________________________________________STATE:_____ZIP:_______-______FAX#(____)__________________
E-MAIL ADDRESS:_____________________________________________________________________________________
CARD: ____MASTERCARD ____VISA _____CREDIT _____ DEBIT EXPIRATION DATE: MONTH _____ YEAR ______
CREDIT CARD #:________-_________-_________-________ DEBIT CARD #:________-_________-_________-_________
PRINTED SECURITY CODE (THREE DIGIT NUMBER APPEARING ON THE SIGNATURE LINE ON REVERSE): _________
I hereby apply for credit with Seagull International Inc. and to induce the granting of credit to me, I hereby sign this promissory note and promise to pay for the amount of my purchase plus shipping and handling charges and any service charges as detailed in the current sales literature of Seagull International Inc., incorporated herein by reference. I authorize Seagull International Inc. to seek payment of the debt from the credit card mentioned above (charge the card). I also understand that the minimum credit card transaction will be $10.00. If a refund or credit is made by seller, I agree that seller may make such refund or credit by check. If payment is not made through the above card, then I hereby authorize Seagull to bring an action in the courts of Pennsylvania, where the creditor has its registered office or place of business and this transaction is considered to take place, and confess judgment against me for the amount of the debt plus costs of collection and attorneys’ fees of 25%. If the credit card issuer or intermediary institutes an action against the creditor, the signing promissory will be responsible for interest at the highest rate allowed by law and other expenses of seller creditor from the date of charge to the date that seller creditor is paid for the goods sold or the goods are returned in saleable condition. By providing an alternate shipping address, which is not the credit card billing address, I authorize and I am responsible for merchandise shipped to the following alternate
address:___________________________________________________________________________________________
I hereby authorize that this form may be used as a promissory note and credit card payment authorization for multiple future purchases from Seagull International Inc.
witness:_______________________dated:____________/____signed:_____________________________________(SEAL)
CREATE A RUBBING OF THE CARD BELOW:
Place the credit card under this sheet of paper and resting under the above space. Use a pencil or crayon to rub the face of the credit card on the paper so that the raised letters will show on this paper. This tracing will verify the card was presented as an authorized means of obtaining payment of the debt. In the alternative, place a photocopy of the card in the space provided. We must have a legible rubbing or photocopy to process your order.
Be advised that for your protection, Seagull will only ship merchandise to the credit card billing address, until you authorize otherwise with this form. Seagull puts charges against your card when an obligation is incurred. Seagull is entitled to payment for freight and handling charges incurred, even if the buyer/cardholder may be unable to accept delivery or refuses delivery after the purchased goods have been sent.
©20051010
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