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.

Complete the form below, print, sign, and fax to 631-841-0066.

* 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.)

Same as billing address

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

*	Residential or Business Address: Residential / Business

Purchase/Repair:

*	for:	PURCHASE / REPAIR
	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:	Visa / Mastercard / Amex
	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.

https://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 631-841-0066.

Cardholder Signature:______________________________