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Shipping Authorization Form

Please complete this form if you are shipping to a different address other than the billing address. This form gives us authorization to ship to this address. This form is designed to protect you, the customer from fraudulent charges on your credit card. Please sign this form and e-mail it back as a scanned image to If you have any questions regarding this form please feel free to give us a call at: 480-892-9433
I __________________________________(Name) have requested Extreme Wheels Order# _____________ to ship to the following address: Shipping Address:____________________________________________________ City: _______________________ State:________ Zip/Postal Code: ___________ Your Phone: ________________________ Bank Phone:_____________________ Date: ________________ Customer Signature:_____________________________ PLEASE BLACK OUT or BLOCK all numbers on your credit card EXCEPT the last 4 digits.
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