Quality Material Handling, Inc.

Quality Material Handling, Inc.

900 W. Foothill Blvd., Azusa CA 91702 Tel: (626) 812-9722 Fax: (626) 812-6544

Credit Card Information:

Visa Select Card:

Master Card

American Express

Discover

Cardholder's Name

Name here.

Credit Card Number

000-0000-0000

Exp. Date (mm/yy)

MM/YY

Sec. Code

000

(Sec code: 3 digit code on back of Visa/MC or 4 digit code on the front of Amex)

Billing Address:

Street

City

State

Zip

Credit card zip code

Customer Name Signature

Enter Name Here

This form may be e-mailed directly to your sales representative. Thank you.

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download