Print this document, fill out the required fields and then fax to:
East Coast (603) 898-6129 or West Coast (425) 462-5322.

All credit card orders will be assessed a surcharge of 3½%.

CREDIT CARD INFORMATION
(Confidential Information)


Date____________________

Company Name___________________________________  Phone______________________

Fax_______________________________ E-Mail Address_____________________________

Billing Address________________________________________________________________

Shipping Address______________________________________________________________

Purchase Order #______________                   Purchasing Agent_____________________

VISA ( ) MASTERCARD ( ) AMEX ( )                             *Certification Value____________

Credit Card #____________________________________ Expiration ___________________

Name on Card _______________________________________________________________

Phone_____________________________

Authorized Signature ________________________________________

*The Certification Value can be found in the following places: Mastercard / Visa: On the back of the card on the signature strip; American Express: on the front of the card – usually 4 digits.