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Credit Card Authorization
Print this form and fax and continue below

Note: The information below is REQUIRED to process any ALL International Orders

For International orders this form must be filled in and faxed to us. Please print this form, complete and fax this form to authorize your purchase on your credit card. You will also need to fax or email a copy of both sides of your credit card. We will require a clear image of the front and back side of your credit card to process your order. Please make sure both side are cleary readable. If your drivers license does not have your credit card billing address we will require a copy of your credit card statement to show proof of your billing/shipping address.

Fax this form to 1.928.669.6656, Or scan and E-mail us: parts@parkeryamaha.com


The issuer of the credit card identified on this item is authorized to pay the amount shown as the TOTAL. I promise to pay such TOTAL ( together with any charges due thereon) subject to and in accordance with the agreement governing the use of such card.
Please Print Your Name:
I certify I am the card holder and authorize this transaction: check box
I certify I am responsible for this transaction       check box
The address given on my order form is correct: check box
I certify I am responsible for any International Duties & Taxes in my country and If I refuse these fees my credit card used here will be billed by Parker Yamaha  check box
First 4 digits of your credit card:

We will need a Drivers License, or copy of your credit card statement
or Photo ID, showing your credit card billing address.
Something that shows your billing address for your Credit Card. We
will also need a copy of the front and back of your credit card.
This is required for International Orders

You may also scan and E-mail this to us at
parts@parkeryamaha.com

Customer Sign Here:
Date Signed:

FOR DEALER USE ONLY: Pick Number Cust Number
Verified By Date
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