Credit Card Payment Form

Complete the form below and click continue at the bottom.

Complete the form below, print, sign, and fax to 516-794-0066.

* Required Fields

BILLING INFORMATION:

* Name:
Department:
* University or Company:
* Street:
* City:
* State:
* Zip:
Country:
E-mail:
* Phone:
Fax:
Tax Exempt Number:
 

SHIPPING ADDRESS: (If different from above address.)

* Attn:
Department:
* University or Company:
* Street:
* City:
* State:
* Zip:
Country:
* Phone:

Purchase/Repair:

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

* There is a minimum order of $25.00.

 

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 Adobe Reader installed on your computer. You can download Adobe Reader free from the Adobe web site below.
Get Adobe Readerhttp://www.adobe.com/products/acrobat/readstep2.html


* If you are not able to open PDF file, print this form, sign at the bottom and fax to 516-794-0066.

Cardholder Signature:______________________________