Credit Card Order Form – via Fax


Please complete all required fields, print (click "Continue") and fax to us at 631-841-0066.
Shipping address must include street address. UPS does not deliver to post-office boxes. For the credit card information, if preferred, you can call us at 800-445-7914 or you can request us to call you.

* Required Fields

BILLING INFORMATION:

* Name:
Department:
* University or Company:
* Street:
Street2:
* City:
* State/Province:
* Postal Code:
E-mail:
* Phone:
Fax:
Tax Exempt Number:
 

SHIPPING ADDRESS: (If different from above address.)

* Name:
Department:
* University or Company:
* Street:
Street2:
* City:
* State/Province:
* Postal Code:
* Phone:
* Residential or Business Address: /

Purchase/Repair:

* for: /
Quotation Number:
Model No. Unit Price Qty. Extension
US$ US$
US$ US$
US$ US$
US$ US$
US$ US$

* Shipping / Handling Fees will be added to the total amount and be charged if applicable.

Additional Request:

 

Payment Information:

* Credit Card Company: / /
Card Number:
Expiration Date: /
Verification Code:

(Verification Code is three digits after your card number which is shown on the back of the card.)

* Cardholder's Name:
* Cardholder's Address:


* The following page requires that you view and print PDF files.
You must have Acrobat Reader installed on your computer. You can download Acrobat Reader free from the Adobe web site below.
Get Acrobat Readerhttps://www.adobe.com/go/getreader


* If you are not able to open PDF file, print this form, sign at the bottom and fax to 631-841-0066.