CREDIT CARD AUTHORIZATION FORM 

Surname :______________________ 

First Name:___________________________ M.I.:___________ 

Credit Card Billing Address: ___________________________________________________________ 

City:______________ State:_____________ Zip Code: ___________ Country:
________________ 

Phone:_______________ Work Phone:__________________ Cellular#:
_________________ 

Fax#: ________________________ 

Email Address: ______________________________________ 

 This is to authorize Graceway IGA/Gourmet Stores to charge my credit card 
for the products ordered. 

Encircle method of payment: AMERICAN EXPRESS  - VISA  - MASTERCARD -  DISCOVER 

Credit Card Number: ___________________________________

EXP. DATE:______________ 

Name as it appears on the card: _________________________________________________________ 

AMOUNT TO BE CHARGED (ONE TIME ONLY): ______________________________________ 

SIGNATURE: _________________________________ DATE: __________________ 

***Please fax or email this form with a photocopy of both sides of the credit card and Photo ID to the below.  

Graceway IGA/Gourmet 

Providenciales,Turks and Caicos Islands, BWI 

Graceway IGA Tel#: (649) 941-500 Fax#: (649) 941-5001 
Graceway Gourmet Tel#: (649) 333-5000 Fax#: (649) 333-5001 

Email: customerservice@gracewayiga.com