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Customer Credit Card Authorization Form

Audio Video Service Labs
829 Lynnhaven Pkwy Ste 128
Virginia Beach, VA 23452

CREDIT CARD AUTHORIZATION

This is to authorizate Audio Video Service Labs Inc (a Kenwood Authorized Service Depot) to charge repairs for my ______________________________________________________________

Claim # ______________________ to my

Visa / Master Card / American Express / Discover number ________________________________________________

Exp Date _____________

CVV2/CVC2/CID Number ________________ (See back of Credit Card)

Billing Name:

Billing Address:

Billing City / State / Zip:

Please ship my product as follows:

(You need not complete this section if the shipping address is the billing address.)

Shipping Name:

Shipping Address:

Shipping City / State / Zip:

Signature of Credit Card Holder: ___________________________________

Print Signature Name:______________________________________

Date:

Fax Reply: (757) 340-6809

For the customer's protection we will charge repairs to this credit card only as authorized above. We do not keep your credit card information on file for any future repairs. WE DO NOT ACCEPT DEBIT / CHECK CARDS on mail order sales. I understand that all parts sales are final.