Scooter Sports

I, ________________________________________________________
(Must Be Actual Purchaser and Card Holder)

AUTHORIZE EZ Burger Company, LLC dba Scooter Sports to charge my VIZA MasterCard (Circle One) credit card number #:

__________________________________________, EXPIRES:_______
Billing Address for Credit Card and Shipping Address (with zip code):
___________________________________________________________
___________________________________________________________

in the amount of $ __________________ for products purchased from EZ
Burger Company, LLC dba Scooter Sports on:

(date) ____________________________.

Signed: ____________________________________________________

Name (Printed):______________________________________________

Address For Card Billing :______________________________________

Telephone number (with area code):___________________________________________

TO COMPLETE CREDIT CARD PURCHASE, PLEASE
FAX SIGNED FORM BACK TO EZ Burger Company,
LLC dba Scooter Sports AT:

1-602-957-8783