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CREDIT CARD PAYMENT FORM |
We gladly accept Mastercard, Visa, Discover, and American Express. |
Due to the security issues inherent with on-line commerce and data storage, we have chosen to handle credit card payments through a secure fax line instead. If you wish to pay for your order with a credit card, please print and fill out the form below. and fax it to us at (678) 482-0771. |
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Organization: |
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Bill to address on statement: |
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Person placing order: |
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Name on card: |
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Credit card number: |
_________ - ________ - _________ - __________ |
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Expiration date: |
______ / ______ |
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CVC/3 digit code on back of card: |
______ |
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Signature: |
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Does your card have a per diem limit? If so, what amount should we charge each day? $________ |
| Is this an official purchasing card? If so, what is the customer code for the card? _________ |
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