Credit Card Authorization Form

I, ___________________________ , hereby authorize HL Technology, to make charges in the amount of $________________ CAD  to my Credit Card in consideration for computer hardware and system order as requested by me, the card holder of this credit card. 

HL Technology Order Number: ________________

Credit Card Type:  Visa ___   Mastercard ___ American Express ___ 

Credit Card Number: _____________________________   Expiration Date: _____________

Card ID:____________  (3 digits after the card No. on back of credit card)
Billing Name (as it appears on credit card): _________________________________________
Billing Address (where credit card statements are sent to):
                                                                         _________________________________________
                                                                         _________________________________________
Shipping Address: ________________________________________________

Cardholder signature: _________________________________________
Date: ______________________

*** PLEASE PRINT THIS PAGE OUT AND FAX TO 604-214-3576.  PLEASE INCLUDE A COPY OF THE CREDIT CARD, BOTH FRONT AND BACK, ALONG WITH YOUR PICTURE I.D. (DRIVER'S LICENSE, MILITARY I.D., ETC.) ***