Accepted Payment Method

MasterCard, Visa, Discover, American Express

Invoice # __________________

Card Number ___________________________ (enter numbers without spaces)

Expiration Date _____ / _____ (mm / yy)

Amount __________________

Authorization Code ______________

Customer Billing Information

First Name ___________________ Last Name ______________________

Company ____________________________________________________

Address _____________________________________________________

City ___________________ State/Province ________ Zip Code ________

Phone _________________ Cell ________________ Fax______________

Email _______________________________________________________

Shipping Information

First Name ___________________ Last Name ______________________

Company ____________________________________________________

Address _____________________________________________________

City ___________________ State/Province ________ Zip Code ________

Phone _________________

____________________________ ______________________ ______

Signature of Credit Card Owner Print Name Date

A copy of both sides of the Credit Card and a copy of a Drivers License or valid I.D must be faxed with this authorization form for credit card processing.