Contact Laser Copier Cartridges .com -- Order Form

Laser Copier Cartridges .com Net 30 Terms Application

Date Received:
By Whom:

Please fill in all fields below.

Legal Name:

Trade Name:

Corporate Address:

Telephone Number:

Fax Number:

Email Address:

Years in Business:

Name(s) and Title(s) of Principle Owner(s)/Officer(s):

1.

2.

3.

4.

Accounts Payable Manager:
Telephone Number:

Financial References

Bank Name:

Bank Telephone Number:

Bank Address:

Please also include (3) trade references with your application

Billing Address:

Credit Card Number:

Expiration Date:

CVV# (found on the back of the card):

I am the (or one of the) authorized account holders of the credit card above. I, ____________________________, authorize Laser Copier Cartridges .com to charge my credit card for all orders shipped for which payment is not made within 30 days. I agree to pay a 5% surcharge that will be added if payment is not made within 30 days from the invoice date.

I have read, understood and agree to be bound by the Terms and Conditions of Sale (see http://lasercopiercartridges.com/terms.htm [link]) and the Return Policy (see http://lasercopiercartridges.com/returns.htm [link]) currently in effect.

Signed:_____________________________________________ Date:_________________