| Date:________________________________________________________________________
Name of item/machine: ________________________________________________________
Item number: ______________________________________________________________
Card Type: (Circle One) MC / Visa / Amex / Disc
Credit Card #________________________________________________________________
Expiration Date: ____________________________ Security Code: _____________________
(3 digits on back of the card)
Name as it appears on card: _____________________________________________________
Address Card is Billed to: ______________________________________________________
City/State/Zip:________________________________________________________________
Phone: ______________________________________________________________________
Email: ______________________________________________________________________
Shipping Information (if different than billing address)
Shipping Address: ___________________________________________________________
City/State/Zip: _______________________________________________________________
Item Cost: $______________________ Shipping Cost: $______________________
Sales Tax: $______________________ (%6.6 for Missouri Residents or Missouri Pick-up)
Dollar Amount Authorized $____________________________________________________
(item price + applicable shipping charges)
Print or type name: ____________________________________________________________
Signature: ___________________________________________________________________
I agree to pay the above referenced amount.
|
