Alternate Shipping Address Authorization Form
Select the text below to print and fill the information and Scan and email to [email protected]
Purpose: This form authorizes shipment of an order to an address different from the billing address on file. Completion of this form and verification of identification are required before shipment.
Customer Information
Full Legal Name (as on ID): ___________________________________________
Email Address: ________________________________________________________
Phone Number: ________________________________________________________
Order Information
Order Number(s): _____________________________________________________
Date of Purchase: ____________________________________________________
Billing Address (as on file):
Authorized Alternate Shipping Address
Recipient Full Name: _________________________________________________
Company Name (if applicable): ________________________________________
Street Address: ______________________________________________________
City: __________________________ State: ______ ZIP: __________
Country: ____________________________________________________________
Recipient Phone Number: _____________________________________________
Identification Requirement (Required)
Please provide a clear copy or photo of a valid, government-issued driver’s license belonging to the cardholder.
Front of Driver’s License attached
Back of Driver’s License attached
Note: The name and billing address on the ID must match the billing information used for the order.
Authorization & Acknowledgment
By signing below, I confirm that:
I am the authorized cardholder for the payment method used on this order.
I authorize shipment of the order(s) listed above to the alternate shipping address provided.
I understand that providing false information may result in order cancellation.
I acknowledge that once delivery is confirmed to the authorized address, the seller is not responsible for loss or theft.
Cardholder Signature: ________________________________________________
Printed Name: ________________________________________________________
Date: _______________________________
For Internal Use Only - For Kirban Performance Only
ID Verified By: ____________________________ Date: _______________
Approval Status: ? Approved ? Denied
Notes: _______________________________________________________________
