Credit Card Acceptance Form
Fill out this form and fax (253) 541-4030 or mail it back if you would like to make
your orders via e-mail using a credit card. (Visa/ Mastercard/ AMEX/ Discover)

Your Name (As it appears on the Card):_________________________________________

Your HOME Address 
Same as Credit Card Billing):__________________________________________________

City___________________________________________State_______________ZIP_________

Your Home Phone Number:(____)_______________________________

Your Credit Card (Circle one)  Visa   MC    Amex     Discover

Issuing Bank Name___________________________________________

Issuing Bank Phone Number___________________________________
(Located on Back of Credit Card)

Credit Card Number______________________________EXP Date_____

For Visa/MC/Discover users: On reverse side of card, please tell us the last 3 digits that appear on the right: ______________

For American Express users please tell us the 4 digits appearing as plain text on front of card: ___________

We only ship via Priority or other US Mail Systems....with this in mind..would you like to indicate another ship to address for all future orders (i.e. your business address or place of work?)
Orders will be addressed to you only; in care of:

SHIP TO (You) : C/O___________________________________________

ADDRESS:______________________________________________________

CITY:__________________________STATE______________ZIP_________
I authorize AMBUSH CO (Of Worcester, MA) to make all necessary charges to my credit card account listed above as I request through my e-mail address. I understand that AMBUSH CO will confirm each and every order through an e-mail reply before making any charges to my account listed above. I understand that AMBUSH CO will not allow any other person to make charges against the above listed account and that I will not be allowed to change my shipping address without resubmitting a new Credit Card Acceptance Form. I agree to Use the Same E-Mail address for all correspondences related to the use of the credit card above.

The e-mail address I will be using for placing orders will be:__________________________________
(Optional) I choose to use a password pertaining to my credit card account listed above. I will use this password in every e-mail that authorizes
a charge to the above account. The Password I choose will be:___________________
 I have read and agree to all of AMBUSH CO. Terms
and Conditions of Sale located at: http://www.beads2u.com/order.htm

SIGNATURE___________________________________DATE______________

 Visa/MasterCard/ Debit Visa or Debit MC/ AMEX or Discover

You will need to fill this form out each time you use a different credit card or if the expiration date or number on a previously submitted card has changed.

We will Always use the Last Card you Submitted for future orders unless otherwise instructed. If your unsure of which card is the last one on file...inquire by calling 508-755-2674

We will only give information containing the last four digits of card in question.

You MUST Snail Mail or Fax This Form...You cannot e-mail this form back...Signature Required.

AMBUSH - Wholesale Beads & Findings

PO Box 144

Worcester, MA 01613

Fax: 253-541-4030

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