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CREDIT CARD AUTHORIZATION FORM

This document authorizes INFOTECH USA, INC., or its affiliate to charge your credit card for payment

Cash Type:

Visa

Master Card

American Express

Discover

Credit card number:

Expiration date:

Card verification number (3 digits code for MC/Visa/Discover and 4 digits for American Express):

Card holder’s name (exactly as it appears on card):

Name of credit card issuing bank:

Tax Exempt # (if Applicable):

Purchase Order # :

E-mail Address :

Billing Address (As appeared in credit card statement):

Please check this box, if billing &shipping address are same

Name:

Shipping Address (If different then billing)

Company Name:

Name:

Address 1:

Company Name:

Address 2:

Address 1:

City/State/Zip:

Address 2:

Phone #:

City/State/Zip:

Fax #:

Phone #:

Qty

ISBN (Book #)

Name of Title & Author

Each Price

Amount

Sub Total:

(New York residents, please add 8.65% Sales Tax)

Sales Tax :

Shipping Charges:(Add $5.95 for first book and $0.95 for each additional book)

Shipping :

Total charge to credit card :

Please enclose a list of books, if you have order for 6 or more titles

I agree to pay the above charges according to the card issuer’s agreement. I understand that my signature on this contract will serve as my authorization on the credit charge slip and as a signature on file for all authorized charges and outstanding balances now and in the future. As registered user of this credit card, I authorize INFOTECH USA, Inc., to ship this order to address requested on my order, and I am responsible for any person receiving this order, if selected the different address then billing address. I UNDERSTAND THAT USING A CREDIT CARD FRAUDULENTLY IS ILLEGAL AND CHARGES WILL BE PURSUED TO THE FULL EXTENT OF THE LAW

Cardholder’s signature

Today’s Date:

Please fill in all the fields, print, sign, date and fax to 516-568-0566

If your shipping address is in New York state and you are tax exempt, please fax a copy of tax exempt certificate with this form.