Phone number: 631-
Fax number: 631-
www.scmdistributors.com
FAX
ORDER FORM
Contact Name:
________________________________E-MAIL:__________________________
Company
Name: _______________________________________________________________
Phone Number: ___________________________ Fax Number: ______________________
Billing Address: _______________________________________________________________
(as it appears on credit card statement) _______________________________________________
City, State & Zip Code: __________________________________________________________
Phone Number (linked to credit card account): ________________________________________
Ship to Address: _______________________________________________________________
_______________________________________________________________
City, State & Zip Code: _________________________________________________________
Credit Card Holder’s Name: _____________________________________________________
Credit Card Type: ______________________________________________________________
Credit Card #: _________________________________________________________________
Credit Card Expiration Date: ____________________________________________________
CID Number
(Card Identification Number): ________________________________________
(3 digits on back for Visa and MasterCard or 4 digits on right front of
AMEX above card #)
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SHIPPING |
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TAX (if in
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I pledge that
all the information above is legitimate and accurate.
I authorize the use of my credit card for this
purchase and agree to the Total cost of this purchase.
Signature:
__________________________________________________________ Date:____________________