Computer Station Corporation

Credit Card Authorization Form

If you are a first-time buyer and will be paying by credit card, please print this form, fill it out and fax it to 713-777-3431. The following information is required for your file at Computer Station Corporation. Following completion and submission of this form, you will be issued an account number for use during future purchases with Computer Station Corporation.

NAME:
E-Mail Address:
BILLING ADDRESS:
CITY: STATE: ZIPCODE:

CREDIT CARD COMPANY: VISA MasterCard American Express
CREDIT CARD ACCOUNT NUMBER:
EXPIRATION DATE:

I, , Title, , hereby authorize CSC to use the above written Credit Card number for payment on orders placed for the purchase of CSC products, as instructed in the Product Ordering Form. I agree to inform Computer Station Corporation in writing of any changes on the credit card including expiration dates, and if the card should become invalid, lost or stolen. I agree to perform the obligations set forth in the card member's agreement with the issuer. I also agree to all shipping, handling, insurance and other charges listed above. CSC will verify all information prior to the use of the credit card.

APPLICANT'S PRINTED NAME:
APPLICANT'S SIGNATURE:
DATE: