Customer Authorization Request Form

Please complete all of the information below to insure prompt processing of your information.  Incomplete customer requests will not be processed.  Your credit information must be checked and approved before orders can be placed.

BILLING INFORMATION

SHIPPING INFORMATION

CREDIT REFERENCES

Provide at least 3 Credit References with

Company Names, Addresses, Account #'s, Contact Name & Phone Numbers:

Provide your Banks Name, Address, Acct.# and Credit Card information.

Banking Institution Information:

Credit Card #:

Type of Card: 

Expiration Date:

Name on Credit Card:

Billing Address:

Phone #:

DECLARED PURPOSE OF EQUIPMENT USE

Please provide information about how you will be utilizing equipment purchased, where it will be located, who will be using the equipment and what it will be used for: (resale, export, office, personal, etc.)

STATEMENT OF AFFIRMATION 

(Checking this box affirms your approval and declaration of true statements.)

    I agree I have been honest in answering all the questions above and have not provided any information which is not true.  I agree that all references may be contacted and information verified before being allowed to purchase and receive equipment from this company.  I state that this equipment will be used in a legal manner and I have not misrepresented any statements about the end use of any equipment I will receive.