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 sales@extremewheels.com. 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.