Wayne Herndon Rare Coins, Inc. :: Secure Online Listing Payment Form

Secure Online Listing Payment Form

NOTE: Using the ENTER key will cause the form to be submitted incompletely. Use your mouse or the TAB key to move between the fields.

Purchase From:
	eBay		Amazon
	Collectors Corner		Yahoo
	Collectica

	E-Mail

	Auction User ID	eBay, Amazon, Yahoo Only
or
	Order Number	Collectors Corner Only

Amount to charge (from item description or our post-listing e-mail):
	Order subtotal
	VA Sales Tax	VA residents only (5%)
	Shipping	We will calculate for Collectors Corner items
	Total
Notes:


Shipping Information:
	Name
	Address
	City (APO/FPO)
	State
	Zip Code
	Telephone

Payment Information:
	Credit Card Type:	Visa		Discover
		Mastercard		American Express
	Credit Card Number:
	Expiration:

	CVV Number (3 or 4 digits on back of card):

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