Return to Used Wheelchairs USA.

Thank you for purchasing from Used Wheelchairs USA! To finalize your order, please print, complete, sign and fax back this form to 915-990-5032, or mail it to the address below, so that we can authorize your credit card details. If you have questions, please call us today at 540-721-3327 (Virginia).

To receive a copy of this form by email, please fill in your email address and (optionally) your name and contact phone number, and press SEND.

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Used Wheelchairs USA: Credit Card Authorization Form

From:  

Phone: Fax:  


To:
Used Wheelchairs USA, Raub's Internet For Business LLC
325 Waterside Drive
Moneta, VA 24121

Phone: 540-721-3327 Fax: 915-990-5032


Shipping Name:  

Shipping Address:  

Shipping City, State, Zip:  


Billing Name:  

Billing Address:  

Billing City, State, Zip:   (Give name and address as they appear on your credit card statement)

Credit Card #:  

Expiration date: CVV #:   (CVV is the 3-digit number on back of Visa/Mastercard/Discover, 4 digit number on front of AMEX)

Is this a Company or Corporate card: (YES or NO)  

Item Purchased: Pride Mobility Jazzy Select 6 Ultra (#690).

Amount: $1645 (With new batteries for $150. You pick up in Virginia.) 

I understand that item(s) listed on this form may have been sold when this form is received by Used Wheelchairs USA, and that prices listed are valid for today only and are subject to change. I also understand that wheelchairs purchased from Used Wheelchairs USA are used, not new. I authorize this charge to my credit card, by Raub's Internet For Business LLC.


Authorized Signature: Date: 06/17/2019  

Fax back to: 915-990-5032

Return to Used Wheelchairs USA.