Credit Card Billing Form

 

(You may fax or call in this information.  Please DO NOT email you card number or expiration date.)

We accept VISA ™ or MasterCard ™ credit and debit cards.

 

 

 

Card Type :

VISA

[_____]

 

MasterCard

[_____]

 

Card Number :

 

     

 

 

 

 

 

 

Expiration Date :

 

 

 

 

V. Code :

 

 

month

 

year

 

 Last 3 digits on back of card.

 

Card Holder Name

 

 

Card Holder Address

 

 

Card Holder City / State / Zip Code

 

 

 

Invoice Amount

$

 

Shipment No.

 

 

I agree to pay the above total amount according the card issuer agreement, and according to the terms and  conditions of the Bill of Lading.

 

Card Holder Signature :

 

Date:

 

 

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Last modified: 10/10/06.