One Time Credit Card Payment Authorization Form



36957007620211 Sinclair Road, Suite 100Bristol, PA 1900700211 Sinclair Road, Suite 100Bristol, PA 19007769620-190500One Time Credit Card Payment Authorization FormSign and complete this form to authorize Metaphase Technologies, Inc.., to charge the credit card listed below. By signing this form, you give us permission to charge your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any other transaction.Please complete the information below, then email to: orders@metaphase-Please Assign a Number for Your Reference: CC <enter your reference number>I, <Enter your name> , authorize Metaphase Technologies, Inc. to charge my credit card account indicated below for $<enter amount> on or after <select a date>. This payment is for <enter a brief description of goods/services> Billing Information:Company Name<enter company name> Billing Address <enter company address> Phone# <enter company phone number>City, State, Zip <enter city, state, and zip code> Email <enter e-mail address> Shipping Information (if different from above):Company Name <enter company name> Shipping Address <enter company address> Phone# <enter company phone number>City, State, Zip <enter city, state, and zip code> Email <enter e-mail address>Items Being Purchased with description and quantity:Quantity:Part NumberDescriptionQuantityUnit Price<enter part number><enter description><enter quantity><enter unit price><enter part number><enter description><enter quantity><enter unit price><enter part number><enter description><enter quantity><enter unit price><enter part number><enter description><enter quantity><enter unit price>38328606985211 Sinclair Road, Suite 100Bristol, PA 1900700211 Sinclair Road, Suite 100Bristol, PA 19007906780-254000After emailing this completed credit card form OR your written purchase order showing credit card payment terms to?orders@metaphase-, ?please call 215-639-8699, ext 111, 103 or 301 with your credit card informationShipping method:Please select your preference:? UPS <enter account number> ? Ground ? Ground Collect ?Red ? Blue ? Other <please specify other>? Fedex (not Fedex ground) <enter account number> ? 2 day ? 3 day ? Overnight ? Priority Overnight? Other carrier (not Fedex Ground): <please specify other carrier> <please enter account number> ................
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