Credit Card Authorization Form

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Credit Card Authorization Form

AnySystem ∙ 239 Braen Avenue ∙ Wyckoff, NJ 07481
Tel: (201)444-6110 x122 ∙ Fax: (201)447-4321

Credit Card Authorization

Date:

CREDIT CARD BILL TO INFORMATION
Company:
Name:
Address:
Tel:

"SHIP TO" INFORMATION
Company:
Name:
Address:
Tel:

Equipment Purchased:

Equipment Price:

________________________________

Shipping Cost:

________________________________

TOTAL COST:

________________________________

Credit Card Type:

________________________________

Credit Card # ________________________________ Expiration ________________________________

Please include CSC # from the back of your credit card: ________________________________ This is a 3 digit number on the back of your card. If you need more information, please contact Dave at the number above.

I, ________________________________ authorize a charge in the amount of USD$ ________________________________ to the above listed credit card.

Signature: ________________________________

A photocopy of the front and back of the credit card is necessary for processing. Please include a copy when returning this form.

Fax completed form to: 1-201-447-4321 or scan and return via email.

Part & Systems

All parts are covered by our 12 Month Bumper-To-Bumper warranty. If you are unsure of the part you require, email our technical department at support@anysystem.com for assistance, as they are eager to help you. If you require a quote or delivery details please send us an email or call us at 201-445-3122.

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AnySystem.com specializes in the support of Self-Maintainers!!! AnySystem's staff has the experienced staff and knowledge to assist you in being successful in providing on-site services for your IT systems.We can also provide on-site technical services for most locations that you do not have technical on-site staff.

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