Cosmo Auto Parts

Credit Card Authorization

CREDIT CARD AUTHORIZATION FORM

Name *
Name
Phone
Phone
Fax
Fax
Expiration Date *
Expiration Date
PART REQUESTED
Ship to: (if different than billing address)
Name 1
Name 1
I hereby authorize Cosmo Auto Parts to charge my credit card for the above amount. I understand that this form with my signature is a binding agreement for this order. I understand this is not a receipt but an authorization. I understand my warranty will be stated on the actual receipt. Freight is NOT refundable for any reason

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6033 E. Mount Houston Rd, Houston, TX 77060

Ph 281-942-4747 / Cel: 832-997-2269 / Fax: 281-942-4748