Network Analysis SCS, Inc. – Credit Card Purchase Authorization
Agreement
This form authorizes Network
Analysis SCS, Inc. to automatically debit / charge my credit card according to the
prices, shipping and fees for all monies due per Online Email Proposal or
Purchase Order.
(Please Print Legibly)
CREDIT CARD BILLING: VISA MASTERCARD DISCOVER (Circle
Card Type)
CARD NUMBER: ____________________________________________
EXPERATION DATE (MM/DD/YY): ____________________________
VERIFICATION # 3 or 4 Digit on Back: __________________________
COMPANY NAME: ____________________________________________________________
CARD HOLDER NAME: ________________________________________________________
CARD HOLDER ADDRESS: _____________________________________________________
CARD HOLDER PHONE: _____________________________ Ext: ______________________
EMAIL ADDRESS: ______________________________________
ORDER# or PURCHASE ORDER#: ______________________________________
TOTAL AMOUNT: ______________________________________
● ● ● ● ● ● SHIPPING
ADDRESS ● ● ● ● ● ●
COMPANY NAME: _________________________________________________
NAME: ___________________________________________________________
ADDRESS: ________________________________________________________
CITY:
ZIP: _____________
PHONE: ______________________
Ext: ______________
AUTHORIZED SIGNATURE: ________________________________________
PRINT NAME: ____________________________________________________
DATE: / / 2012
Any required return orders
are subject to a 25% restocking charge.
Any Opened Products Boxes or Plastic Packaging are Not
Returnable.
119 Sunset Drive