Credit card authorization form

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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

Credit card authorization form

Signature of Cardholder:_________________________________________________________________________

Printed Name of Cardholder:_ __________________________________________________________

Date of Order:_____ __________________________________________________________________

Printed Name of Cardholder:_ __________________________________________________________

Date of Order:_ ______________________________________________________________