Because of changing laws regarding non-signed credit cards, HPD requires this form be filled out and signed for each credit card used.

We will not accept credit cards without this form

Date: _________________
Dealer Name:________________________________
Dealer Phone Number: ________________________
Banking Information:

Bank Name:______________________ Phone Number:___________________
Bank Address:_____________________________________________________
_________________________________________________________________

Bank Contact:____________________________

Polaris Dealers Provide Dealer Number: ______________
Company Credit Card: Visa / MasterCard / Discover

CC Number: _________-__________-__________-___________(required)

Expiration Date: ______/_______ V-Code (on back of card):__________

Name on Card:_______________________________________________

Billing Address:______________________________________________
___________________________________________________________

Authorized Signature:__________________________________(required)

Authorized Signature #2:______________________________________

Fax and then mail to:
High Performance Designs, Inc.
29940 Hwy 169 NW, Princeton, MN 55371
(763)389-3336 Fax: 763-389-1474