Credit Card Payment Authorization Form

Name: _______________________ authorizes Simplicity Marine Products, Inc.
to charge the following credit card for purchases made from Simplicity Marine
Products, Inc.

Credit Card Type:     Visa            MasterCard

Account No: ________________________________________

3 numbers code on back of card ________________________

Expiration Date: ______/______

Name on Credit Card: ________________________________

Billing Address for Card: ______________________________

City ________________________ State __________________

Country______________    Postal Code __________________

Phone # __________________________




Sale Amount approved: $___________USD
plus shipping and 3% paperwork & processing fee will be added


Signature: ________________________________ Date ___________

 On international purchases please send copy of Pass Port or Drivers License and
copy of Credit Card front and back.

 E-mail or Fax completed form and copy of Pass Port, drivers license and   
 front and back of Credit Card  to  Fax 727-499-7457 

OR   E-mail

On Behalf of the Simplicity Products Team, We Appreciate your Business and Look
Forward to Helping you with your needs in the future.


Simplicity Marine Products, Inc.
635 43rd St. Blvd. W.
Palmetto, FL 34221 U.S.A.
(941) 722-8475 - Phone
(727) 499-7457 - Fax