Name on Card:_________________________________________

Address:______________________________________________

Address:______________________________________________

City/Town:_____________________________________________

State/Province:________________________________

Zip/Postcode:_________________________

Country:______________________

Telephone:  __________________________________________

"X" Type of Card:  Visa ____  MasterCard ____  AMEX____

Card Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

Expiration Date: ____/____    CVV2 Code: __ __ __ __ (Last 3 or 4 digits on back of the credit card)

I agree to pay the total amount as entered above according to the card issuer agreement.  I also understand that I am responsible for all shipping costs to return any merchandise for refunds or exchanges. I am also responsible for the shipping costs to return exchanged merchandise back to me.

Cardholder signature:_____________________________________

Date:____________________

NOTE: 

• Charges appear as Sly Fox MX Closeouts on your credit card statement.
• All credit card information is kept strictly confidential and will not be given or sold by Sly Fox MX Closeouts.
• Contact us with any questions:  317-861-8478 or email: Support@SlyFoxMX.com

Fax this completed form and the above credit card page to:      

 011-317-890-0447  or  1-317-890-0447

Thank You!