Credit Card Form - KTI Promo

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Phone: 800-275-6387. Fax: 713-266-3893. Salesperson ______. Sales Associate ______. Please Fax back to: 713-266-3893. Credit Card Authorization.
10415-A Westpark Drive Houston , Texas 77042 ASI: 63776

1-800-275-6387 (phone) 713-266-3893 (fax)

PPAI: 238818

SAGE: 67071

S/O #:

Credit Card Authorization

Customer ID: PO#:

Customer Information

Order Date: Bill To:

Ship To:

(Company) (Contact) (Address)

(Phone) (Fax)

Credit Card Information Yes

Keep this card on file?

No

Yes

Commercial Card? Exp Date:

Card Number: M/C

American Express

Visa

Discover

Cardholder Name

CSV*:

Cardholder Signature:

X

Billing Address: City, State, Zip: Email Address for Invoice and CC Receipts:

Shipping Information Method of Shipment: Use this account#: Item

This account belongs to

Description

Quantity

Unit Price

I hereby authorize KTI Networks, Inc. to charge my Visa, MasterCard, American

Sub Total

Express, or Discover Account for my order stated above. I agree to pay any

Shipping

additional charges and chargebacks related to the shipping of this order.

Tax

Price

Total *What is CSV? - It is the 3-digit # on back of your Visa, MC, or Discover, or the 4-digit # on front of your AMEX.

Salesperson

Sales Associate

Upon artwork approval and a 50% deposit, your order will be submitted into production. Remaining balance will be charged on the day of shipping. Full payment must be received before the order ships.

Please fax back to 713-266-3893

No