BANKCARD TRANSACTION FORM
FAX to AAAmachine, Inc. (+1-847-376-3530)
[pic]
SERVICE REGISTRATION FORM
with Credit Card/Forwarder preference information
To AAAmachine i-BES site visitors,
Thank you for visiting AAAmachine i-BES site. In order to utilize our e-commerce service, we would like to receive your basic information as follows. This information is only used for the i-BES service and communicating between you and AAAmachine. We will not share your information with any other party. Your credit card information will be stored in a separate secure server from i-BES e-commerce server.
This form must be completed and faxed by the person responsible for the credit card account. Transaction will NOT be processed until the ordered equipment/parts are shipped. We will reply you with ID and password for you to log-in the i-BES site.
TYPE OF CARD: VISA____MASTERCARD____
CARD NUMBER:_____________________________________________________
EXPIRATION DATE:________________________
NAME ON CARD:____________________________________________________
COMPANY NAME:______________________________________________________________________________
COMPANY ADDRESS:___________________________________________________________________________
CITY: _______________________________________ STATE: _____________ ZIP CODE:________________
COUNTRY: _________________________________ YOUR NAME: __________________________________
YOUR E-MAIL:________________________________________________________________________________
TELEPHONE # :___________________________________ /FAX # :_________________________________
Preferred Forwarder to be used for international/domestic shipping and account number
( ) Fedex, ( ) UPS, ( ) DHL, ( ) other [___________________]
Your account number: ___________________________________
SIGNATURE OF CARDHOLDER_________________________________________________________________
If you have any questions, please feel free to contact us. Revised 06/01/09
AAAmachine, Inc. 1291 Rand Road, Des Plaines, IL 60016 USA, Toll free: 800-996-0070
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