Shipping/Credit card Authorization Form (Form to be filled out by card holder)
Sale amount : $-----------------------------plus shipping of $--------------------------------
Credit Card Number: --------------------------------------------------------------------------
Expiration Date : ----------------------------------------------------------------------------
Last three numbers in signers block on back of card (if applicable):--------------------------
Billing Information
Full Name on Card-----------------------------------------------------------------------------
Contact phone no.:----------------------------------------------------------------------------
Card Address: --------------------------------------------------------------------------------
City: State: ---------------------------------------------------------------------------------
ZIP Code: ------------------------------------------------------------------------------------
Country: -------------------------Email Address:----------------------------------------------
Shipping information (If picking up at a terminal- State "Terminal pick-up") 

Name: ----------------------------------------------------------------------------------------
Address: -------------------------------------------------------------------------------------
city: State: ---------------------------------------------------------------------------------
Zip;------------------------------------------------------------------------------------------
I ______________________________ hereby authorize IMP to charge my credit card 
number: _________________________________________exp. date____________ for the
 amount of  $________________________ (stated above) for the purchase of  
(item description) __________________________________ including shipping.
Signature ___________________________________________
Date      ___________________________________________
Please accompany this form with a copy of the card (front and back) and send to:
Value Mobility 6003 Sage dr Orlando Fl 32807 or FAX to 407 381 8039