One name per line.
Please include any items that can be purchased with the credit card. One item per line.
If for any reason you are unable to complete this online form, please download this printable PDF version.
Print, complete and sign the form. Please include a copy of your Drivers License or State ID.
Mail your completed credit card authorization letter to:
Miranda Country Store
16-186 Wiliama Street
Keaau, Hawaii 96749
Or fax to: 808-969-3250
Or email to:
email@example.com AND firstname.lastname@example.org
Call Sammie: 808-935-4457