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Payment by Credit Card Form
  Company Name:
  Corporation Name:
  Address:
  City:
  State:
  Zip:
  Phone #:
  Fax #:

  Invoice #   Total  
  Invoice #:        
  Invoice #:        
  Invoice #:        
  Invoice #:        
  Invoice #:        
  Credit Memo (If any):        
  Total of all invoices:    

Credit Card Information   
 

Type of Credit Card: Master Card, Visa, Discover, American Express

 

C.C. #:

 
 

Billing Address:

 
 

City:

 
 

State:

 
 

Zip:

 
  Amount you want us to change:  
 
  Signature: ___________________
       
  Important Notice
  If any dispute in the invoice please do not just deduct the amount. Send us the copy of the invoice and let us know why the money is being deducted. If any deduction taken without proper paperwork, your account will get put on either COD payment terms, if not your signature will be required to approve all the prices and orders, before itís shipped; which could delay the shipment.
Please print, and complete the form. Fax it to us @ 214-745-8876
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