| Complete First And Last Name (Billing) |
|
| Complete Billing Address Please Include City State
Zip Code (Billing) |
|
| Business Or Home Phone With Ext # ( Please Include
Area Code) (Billing) |
|
| Other Phone (Billing) |
|
| Fax Number (Billing) |
|
| Special Billing And Shipping Instruction. (UPS Pick
Up Address) (Based On Payment Method) Instruction. |
|
| Amount Of Purchase (Billing) |
|
| Payment Method (Billing) |
|
| Complete Credit Card # (Billing) |
|
| Expiration Date (Billing) |
|
| Security ID (Four Digit code on back of card)
|
|
| When Paying By Business Or Personal Check Please
Include The Following Information. Full Name As It Appears On Front Of The
Check (Billing) |
|
| Bank Name (Billing) |
|
| Bank Account Type (Billing) |
|
| Account Number (Billing) |
|
| Routing Number (Billing) |
|
| Representative Name (Billing) |
|
| Email Address: |
|
| LETTER OF AUTHORIZATION.*I HAVE READ THE TERMS AND
CONDITIONS OF IMAGEWRITE CORP AND UNDER STAND THAT I HAVE 72 HOURS TO
CANCEL MY PURCHASE WITH IMAGEWRITE CORP BY ENTERING MY FULL NAME IN THE
BOX TO THE RIGHT. I HAVE AUTHORIZED IMAGEWRITE CORP MERCHANT ACCOUNT TO
CHARGE MY CREDIT CARD / BUSINESS OR PERSONAL CHECKING ACCOUNT FOR THE
AMOUNT OF MY PURCHASE. ( PLEASE ENTER YOUR COMPLETE NAME IN THE BOX TO THE
RIGHT. ) |
|
| Complete First And Last Name (To Appear On
Ad) |
|
| Complete Company Name (To Appear On Ad)
|
|
| Complete Address Please Include City State Zip Code
(To Appear On Ad) |
|
| Special Instruction (To Appear On Ad) Please
Include all States Counties and Listings and Banners Purchased and Amount
of Purchase |
|
| Description Of Products And Services (Tell us what
you do ) (To Appear On Ad) |
|
| Description of Discount (Not Required)(To Appear On
Ad) |
|
| Website / URL Address (Do you have a
Website) |
|
|
|
