Portland Furniture Online

Credit Card Authorization Form

1. Fill out the Credit Card authorization form below
2. Print Completed Form
3. Sign and date below
4. Attach a copy of the credit card and I.D.
5. Send Form, and copies of credit card and I.D. to Portland Furniture Online 
A. Fax - (503) 546-1037
B. Mail - Portland Furniture Online 1971 W. Burnside Portland, OR 97209

Credit Card Holder Name
*The address entered must match the address where the credit card bill is received
Credit Card Billing Address
City
State
Zip Code
Phone
Fax (If Applicable)
  
I am charging the following products to this credit card:
 
Credit Card Type (Circle one) Visa Master Card Discover
Credit Card Number
Credit Card Expiration
Charge my card the following amount
I, the undersigned, do hereby authorize Portland Furniture Online to charge the above card in the amount indicated above. I am signing below, acknowledging that I am the cardholder under penalty of law.
Signature of Cardholder                                                                Date                              
Print Form