Credit Card Form

DATA ID SYSTEMS' CREDIT CARD HOLDER'S AUTHORIZATION REQUEST - Fill in form, print out, sign and FAX to (408)354-9533

In lieu of my credit card imprint, I Hereby authorize Data ID Systems to charge my order to the following credit card:

Credit Card

Visa MasterCard American Express Discover

Cardholder name

PRINT Name of Cardholder exactly as Shown on Credit Card

Card number

Expiration date

Month Year (mm/yyyy)

CVV2 Security code

last 3 digits on the back of credit card in the signature field

PO	Your Purchase Order #
10-	Our Order #
30-	Our Invoice #

Credit Card 800 #

appears on the back of credit card

THE BILLING ADDRESS AS IT APPEARS ON MY CREDIT CARD STATEMENT

Street address

Business Residential

Address (cont.)

City

State/Province

Zip/Postal code

Email Address

*required

Phone number

(###) ###-#### ext. ###

Fax number

(###) ###-#### *required for invoice /receipt of charges

Ship my order to the following ADDRESS (you may experience a delay if different from billing address)

Ship to

(the same address as my bill to address) YES - please fill in company name and attention to -

Company Name

Attention to

Street address

Business Residential

Address (cont.)

City

State/Province

Zip/Postal code

This form must be completed in full and all information must be true and correct in order for your order to be processed.

CARD HOLDER AUTHORIZED BILLING SUB-TOTAL AMOUNT:

Special Order

Yes No *If you are unsure, call your account representative for assistance

Sub-total $

Taxable Yes No

Tax $/Freight $

By signing and submitting for payment, I acknowledge acceptance of the Terms and Conditions, accept and agree to all cancellation and/or re-stock penalties and agree to all charges. I also agree in the event of a dispute, requests for a refund must be submitted in writing along with all order documentation in accordance with standard policy of company issuing credit card. We will gladly exchange or accept for return items which are defective and subject to the manufacturer's warranty terms. Special order items and software are non-returnable and non-refundable. All other items MAY, at our option, be accepted for return with a restocking fee or credit to account only as outlined in our terms of sale. This document must be received via secure fax or mail prior to shipment.


- Signature as it appears on cardholder's credit card

Phone 408-354-7733 | Fax 408-354-9533 | email sales@dataid.com