DATA ID SYSTEMS' CREDIT CARD HOLDER'S AUTHORIZATION REQUEST - Fill in form, print out, sign and FAX to (408)354-9533
In lieu of my credit card imprint, I Hereby authorize Data ID Systems to charge my order to the following credit card:
Credit Card Visa MasterCard American Express Discover
Cardholder name PRINT Name of Cardholder exactly as Shown on Credit Card
Card number
Expiration date Month Year (mm/yyyy)
CVV2 Security code last 3 digits on the back of credit card in the signature field
PO Your Purchase Order #
10- Our Order #
30- Our Invoice #
Credit Card 800 # appears on the back of credit card
THE BILLING ADDRESS AS IT APPEARS ON MY CREDIT CARD STATEMENT
Street address Business Residential
Address (cont.)
City
State/Province
Zip/Postal code
Email Address *required
Phone number (###) ###-#### ext. ###
Fax number (###) ###-#### *required for invoice /receipt of charges
Ship my order to the following ADDRESS (you may experience a delay if different from billing address)
Ship to (the same address as my bill to address) YES - please fill in company name and attention to -
Company Name
Attention to
Street address Business Residential
Address (cont.)
City
State/Province
Zip/Postal code This form must be completed in full and all information must be true and correct in order for your order to be processed.
CARD HOLDER AUTHORIZED BILLING SUB-TOTAL AMOUNT:
Special Order Yes No *If you are unsure, call your account representative for assistance
Sub-total $ Taxable Yes No
Tax $/Freight $
By signing and submitting for payment, I acknowledge acceptance of the Terms and Conditions, accept and agree to all cancellation and/or re-stock penalties and agree to all charges. I also agree in the event of a dispute, requests for a refund must be submitted in writing along with all order documentation in accordance with standard policy of company issuing credit card. We will gladly exchange or accept for return items which are defective and subject to the manufacturer's warranty terms. Special order items and software are non-returnable and non-refundable. All other items MAY, at our option, be accepted for return with a restocking fee or credit to account only as outlined in our terms of sale. This document must be received via secure fax or mail prior to shipment.
   
- Signature as it appears on cardholder's credit card
Phone 408-354-7733 | Fax 408-354-9533 | email sales@dataid.com
Copyright 1997 - 2006 Data Identification Systems All Rights Reserved