Fillable Printable Credit Card Information Form - New York
Fillable Printable Credit Card Information Form - New York
Credit Card Information Form - New York
NEW CLIENT / CREDIT CARD INFORMATION FORM
GENERAL INFORMATION
Company Name:
Company Address:
City: State: ZIP Code:
How long at current address?
Phone: ( ) - Fax: ( ) - Website:
Date business commenced:
MM /YYYY
Federal Tax ID Number:
Sole proprietorship
Partnership
Corporation
Other:
BILLING INFORMATION
Billing Address:
IF DIFFERENT FROM ABOVE
City: State: ZIP Code:
Does company have multiple bill to locations?
1
Is company tax exempt?
2
Accounts Payable Contact: Dunn & Bradstreet Number:
A/P Phone: ( ) - A/P Fax: () - A/P E-mail:
Person responsible for placing orders: Will other people be making orders?
3
Ordered By Phone: ( ) - Ordered By Fax: ( ) - Ordered By E-mail:
PAYMENT INFORMATION
Card Number: _________ _________ _________ ________
Exp Date:
MM / YYYY
Security Code*:_______
Visa
Master Card
American Express
Discover
*Security Code - AMEX - 4 digits on the front of the card;
3 digit code in the signature panel of card (V, MC, or D)*
Card Holders Name:
Company Name on Credit Card (if applicable):
Credit Card Billing Address:
IF DIFFERENT FROM ABOVE
City: State: ZIP Code:
Phone: ( ) - Fax: ( ) - E-mail (for receipt):
Card Holders Signature:
By signing, I authorizeMichael Andrews Audio Visual Services to bill my credit card listed above for charges related to my order. I agree to
pay total in accordance to my card issuer’s agreement.
AGREEMENT
•
All orders are subject to the Terms and Conditions as set forth by Michael Andrews Audio Visual Services Inc.
•
Claims arising from invoices must be made within seven business days.
•
All orders are required to be paid for in advance. Acceptable forms of payment includes Check, Credit Card (please complete credit
card info above, and return with a copy of the front and back of the card), Cash (if order is being picked up at Michael Andrews only)
COMPLETED BY
Signature:_______________________________________ Print Name:_________________________________
Title:__________________________________________ Date:_______________________________________
1-
For multiple billing locations please attach a separate sheet indicating: address, local contacts, and invoices that should be billed there
2 -
If tax exempt please attach copies of New York State Tax Exempt Form (ST-119), or New York State Resale Certificate (ST-120). Please note, if
we do not have valid Tax Exempt form or Resale Certificate for you, your invoices will be generated with sales tax
3 –
If there will be other individuals making orders please attach a separate sheet indicating their contact information
