Credit Card Fax Form


178 Sunny Valley Road \| New Milford, CT 06776 \| USA \| FAX 860.354.4757
Print this page and use it to fax (or mail) credit card details to us. (DO NOT EMAIL credit card information)
(check one)	VISA o MasterCard o Discover o	Expiration date: _ _ /_ _
Card Number
Name (as it appears on card)		3-Digit Security Code (on back of card) _ _ _
Phone - daytime	( )
Email Address
Billing Address (billing address must match credit card or order cannot be processed)
First Name
Last Name
Company Name
Address

City and State		Zip Code:
If outside U.S., country & postal code		Postal Code:
Shipping Address
First Name
Last Name
Company Name
Address

City and State		Zip Code:
If outside U.S., country & postal code		Postal Code:
Signature of Cardholder:
(back)