Fax Credit Card Order Form Black's Auto Salvage, Inc 3425 Famco Road - PO Box 209 Brusly, Louisiana 70719 PH (225)749-3161 (800-234-5063) Fax (225)282-0073 Amount : Reference Number : Date : Billing and Contact Information Cardholders Name : Address 1 Address 2 City State Zip Phone Fax No Email Address Credit Card Information Card Type : Card Number : Expiration Date (MM/YY) Shipping Information: (if different than above) Recipients Name : Address 1 Address 2 City State Zip Signature Please Print & Fax To (225)282-0073 (Do Not Use Submit Button) * Indicates Response Required