The Lake Shore Group, Inc.
dba LOWPRICEWIRELESS.com
CREDIT CARD CONSENT FORM
Date:
Online Order Number:
Customer Name:
Customer Address (as it appears on
credit card billing statement):
Customer Phone: ( )
Circle one: MasterCard Visa Discover Amex
Credit Card No:
Expiration Date:
Customer Name (as it appears on card):
Returns & Restocking Policy
Authorization: I,
, authorize The Lake Shore Group, Inc.
(print name of cardholder
and/or LOWPRICEWIRELESS.COM, to charge the above stated credit card for
any products I purchase at www.lowpricewireless.com between 12/01/01 and
12/31/02.
Signature of Cardholder
Please fax back with a copy of your driver's license and credit card (front and back) to 1-702-456-6399 so we can process your order. Select "Photo" or "Fine" options on your fax machine.