Timco Engineering, Inc



TIMCO ENGINEERING INC. Product Testing and Certification

849 NW State Road 45 Newberry FL 32669 FCC Approvals

888.472.2424 or 352 472 5500 Fax 352.472.2030 Industry Canada Approvals

Email: accounting@ Product Safety Approvals

Web: Notified Body for Europe

Payment Authorization Form

Note: ALL information must be completed to process payment

| |Section A – Payer Information | |

|Payee Name (enter name exactly as it appears on your card) |

|      |

|Payee Company Name |

|      |

|Street Address #1 |Street Address #2 |

|      |      |

|City |State |Zip Code |

|      |      |      |

|Daytime Telephone Number w/area code |Country |

|( ) |      |

| |Section B – Applicant Information | |

|FCC ID or Model Number |Timco Invoice Number |Timco Job Number |

|      |      |      |

|Applicant Name |

|      |

|Street Address #1 |Street Address #2 |

|      |      |

|City |State |Zip Code |

|      |      |      |

|Daytime Telephone Number w/area code |Country |

|( ) |      |

| |Section C- Credit Card Payment Information | |

|Master Card Visa Card | American Express |

|Credit Card Number |Expiration Date |

|  |  |

|I authorize Timco Engineering, Inc to charge the |Cardholder’s printed name and signature: |

|above amount to my Credit Card and I will pay the |      |

|above amount according to our agreement. | |

| | |

| |Please Sign Above Month / Date / Year |

| |Date: / / 20 |

|This form must be returned to Timco Engineering, Inc. with Card Holder Signature. |

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