Credit Card Authorization Form - Miranda Country Store

Business and or Individual Name(Required)

Authorized Signatory(Required)

Name as it appears on Drivers License or State ID

Business Phone(Required)

Phone # associated with Credit Card.

Additional Contact Phone

Billing Address for Credit Card(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Names of Individuals authorized to pick up this purchase.(Required)

One name per line.

Contact Email(Required)

Back of your Drivers License or State ID.(Required)

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.

Front of card.

Please upload a copy of your Drivers License or State ID.(Required)

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.

Back of card.

Authorized items for purchase.(Required)

Please include any items that can be purchased with the credit card. One item per line.

I the undersigned authorize Miranda Country Store, Inc. to charge my credit card; inclusive of the 3% service charge, in the amount of $ “to be determined,” for the purchase of the "Authorized items for purchase" listed above.(Required)

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: demellojr@earthlink.net AND mirandacs@hilo808.net

Questions? Call Sammie: 808-935-4457