CREDIT CARD AUTHORIZATION FORM This document authorizes INFOTECH USA, INC., or its affiliate to charge your credit card for payment
Cash Type:
Visa
Master Card
American Express
Discover
Credit card number:
Expiration date:
/
Card verification number (3 digits code for MC/Visa/Discover and 4 digits for American Express):
Card holder’s name (exactly as it appears on card):
Name of credit card issuing bank:
Tax Exempt # (if Applicable):
Purchase Order # :
E-mail Address :
Billing Address (As appeared in credit card statement):
Please check this box, if billing &shipping address are same
Name:
Shipping Address (If different then billing)
Company Name:
Name:
Address 1:
Company Name:
Address 2:
Address 1:
City/State/Zip:
Address 2:
Phone #:
City/State/Zip:
Fax #:
Phone #:
Qty
ISBN (Book #)
Name of Title & Author
Each Price
Amount
Sub Total :
(New York residents, please add 8.65% Sales Tax)
Sales Tax :
Shipping Charges:(Add $5.95 for first book and $0.95 for each additional book)
Shipping :
Total charge to credit card :
Please enclose a list of books, if you have order for 6 or more titles
I agree to pay the above charges according to the card issuer’s agreement. I understand that my signature on this contract will serve as my authorization on the credit charge slip and as a signature on file for all authorized charges and outstanding balances now and in the future. As registered user of this credit card, I authorize INFOTECH USA, Inc., to ship this order to address requested on my order, and I am responsible for any person receiving this order, if selected the different address then billing address. I UNDERSTAND THAT USING A CREDIT CARD FRAUDULENTLY IS ILLEGAL AND CHARGES WILL BE PURSUED TO THE FULL EXTENT OF THE LAW.
