COLLECTOR'S CLUBHOUSE CREDIT CARD AUTHORIZATION FORM

Customer Name___________________________________

Address___________________________________

City _________________________

Province/State________________________

Country_________________________

Postal Code_________________________

Phone  ____________________ 
 
Fax  __________________________

Credit Card number: _____________________________

Type of Credit Card(circle one)  Visa/ Mastercard

Name on Card _____________________ Expire Date______________

Authorized Signature ______________________________

In completing this credit card authorization form I/We authorize Collector's Clubhouse to process charges

to my/our credit card for goods being shipped to us on the basis of orders placed by me/us via

telephone/fax/internet or letter. This authorization shall remain in force until canceled by me/us in

writing or e-mail to Collector's Clubhouse.Please return completed form to: 

101-1184 Denman Street

Vancouver, B.C.

Canada V6G-2M9

 TEL:(604) 681-0035

 OR FAX:(604) 608-6931