Legal Business Name D.O.B: Phone: Email: Credit Card Type: VISA MASTERCARD AMEX Other Other Card Type: Cardholder Name: (as shown on the card) Credit Card Number: Expiration Date: CVC Code Customer Signature Address Golden Eagle Distributors uses an AVS (Address Verification System) to authorize the amount of the charge and authenticate the billing address before approving the charge. If it's wrong our processor will reject the transaction but still put a 2 - 5 day authorization hold on the funds in your account. In order to avoid any unnecessary delays, a $0.10 charge will be processed to verify the billing address entered below prior to your order being charged. State, City, Zip: Today's Date I understand and agree that this form authorizes Golden Eagle Distributors to charge my credit card for orders placed via Telephone, eMail, Web or Fax. I also agree to resolve any disputes directly with Golden Eagle Distributors Submit
