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.
* THIS DOCUMENT IS DESTROYED UPON COMPLETION OF PROCESSING !

(Please Print Legibly)

CREDIT CARD BILLING:      VISA      MASTERCARD        DISCOVER      AMETICAN EXPRESS     (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 CITY: _______________________________ STATE: _______ ZIP: _______

CARD HOLDER PHONE: _____________________________ Ext: ______________________

EMAIL ADDRESS: ______________________________________

ORDER# or PURCHASE ORDER#: ______________________________________

TOTAL AMOUNT: ______________________________________

●       ●       ●       ●       ●       ●       SHIPPING ADDRESS      ●       ●       ●       ●       ●       ●

COMPANY NAME: _________________________________________________

NAME: ___________________________________________________________

ADDRESS: ________________________________________________________   

CITY: ______________________________ STATE: _______________________

ZIP: _____________ PHONE: ______________________ Ext: ______________

PO#, ORDER#: ______________________________________

AUTHORIZED SIGNATURE: ________________________________________

PRINT NAME: ____________________________________________________

DATE:               /             /  2018

 

Any required return orders are subject to a 25% restocking charge.

Any Opened Products Boxes or Plastic Packaging are Not Returnable.

 

 

119 Sunset Drive Berea, OH 44017 Phone: 440 773-4554 Fax: 440 891-1025