Ana səhifə

Credit card authorization form


Yüklə 37.34 Kb.
tarix24.06.2016
ölçüsü37.34 Kb.


CREDIT CARD AUTHORIZATION FORM

Send via Fax 410-465-5257

or Email: Andrea@LaurusSystems.com





Credit Card Number:

Visa: MC:

AMEX: Discover:

     

Expiration Date (ex. 11/2012):

     

Three Digit Security Code:

    


BILL TO INFORMATION:

Cardholder’s Name:

     

Company Name:

     

Billing Address:

(For Credit Card)



     

City

     

State

     

Zip

     

Country


     



SHIP TO INFORMATION; Choose One-Business  Residential 

Company Name:

     

Contact Name

     

Billing Address:


     

City

     

State

     

Zip

     

Country


     


OTHER:

Phone:

     

Fax:

     

Email:

     

Order or Ref No:

     


Order consists of the following:


Qty


Part No.


Description

Unit

Price

Extended

Price

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Please choose your shipping preference on the following page
-Shipping is prepaid by LAURUS Systems, Inc. and added to the invoice when shipment occurs unless you enter your own shipping account. We ship via FEDEX and UPS only.
Top of Form

I would like to use my own shipping account with FEDEX UPS

Bottom of Form

Top of Form

My Shipping Account Number is The billing zip code on my shipper account is

Bottom of Form

Top of Form



I would like LAURUS Systems Inc. to ship and prepay and add to our billing-Some Shipping choices are a premium pay meaning they are more expensive choices-i.e. FEDEX or UPS First Overnight, Saturday Deliver-Same Day
PLEASE CHOOSE YOUR SHIPPING PREFERENCE
Shipping Choices:
FEDEX Ground UPS Ground

FEDEX Next Day (8 am.) FEDEX-Next Day (10:30 am) FEDEX Standard Overnight (3 pm)

FEDEX 2 Day- FEDEX Express Saver (3 Day) Not available to all areas
INTERNATIONAL OPTIONS
FEDEX International Priority FEDEX International Economy

Bottom of Form


I authorize LAURUS Systems, Inc. to charge my credit card a total of ____________________+Shipping if applicable.

Signature of Cardholder:_________________________________________________________________________




Printed Name of Cardholder:_     __________________________________________________________




Date of Order:_____     __________________________________________________________________





3460 Ellicott Center Dr. Ste 101 * Ellicott City, MD 21043 * Phone: 410-465-5558 * Fax: 410-465-5257

email: Rad.Info@LaurusSystems.com * web: www.LaurusSystems.com



Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©atelim.com 2016
rəhbərliyinə müraciət