Authorization Form for Online Purchases

This form, when fully completed and signed, herby gives The Alternative Food Cooperative of Wakefield, Rhode the power to charge the credit card provided below for purchases made on the official Alternative Food Cooperative web site. (www.alternativefoodcoop.com)

Directions: Form must be fully completed for acceptance. The information provided below must match your credit card information or form is invalid. Please print all information in black or blue pen.

Name: ___________________ ____ __________________
           Last                                 M.    First

Home Phone: (_____) _____ - ______

Home Address: 
        ____________________ (Number/Street)
        ____________________ (Town/City)
        ____________________ (State)
        ____________________ (Zip Code)

Billing Address: (if different from above.)
        ____________________ (Number/Street)
        ____________________ (Town/City)
        ____________________ (State)
        ____________________ (Zip Code)

Credit Card #: ___________________________ 

Visa   MasterCard     Expiration Date: ____/____


Co-op Personal Identification Code (C.P.I.C.): ________________________ (Assigned by staff at store.)

By signing my name below I herby give The Alternative Food Cooperative the power to charge my credit card provided above for purchases made by me on The Alternative Food Cooperative's official web site (www.alternativefoodcoop.com) and agree that I am responsible for payment of all purchases except in case of delivery error or Co-op error.

Signature: _________________________________ Date: ____/____/____
                First                    Last