Purchasing Order & Credit Card Authorization Form

If you wish to charge the amount of your advance orders to your credit card account, please complete the information requested below and fax this form to (909)623-4915 Lasermate Group, Inc..
         Purchasing Order             Date (mm-dd-yy):_____ - _____ - ______

QTY          Model No.                 Brief Description                    Unit price            Amount
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
(International shipping: please ask for the cost of freight)
(Shipping 1lb in CA, USA only: 1 week $7.00; 2nd Day $12.00; Next Day $22.00)    SALES  ____________
(Shipping 1lb in USA: 1 week $9.00; 2nd Day $18.00; Next Day $35.00)               FREIGHT  ____________
                                     (8.75% sales tax for California residents)     SALES TAX  ____________
                                                                                                           TOTAL      ____________

Credit Card Authorization Form

Charge to: ____MasterCard ____Visa  ____American Express   Total Amount: USD____________

Card No. : |___|___|___-___|___|___|___-___|___|___|___-___|___|___|___|___|

Expiration Date:|___|___|___|___|                     Security Code (in the back side): |___|___|___|

Cardholder's Name:______________________________________________________

Cardholder's Signature:___________________________________________________

Phone Number: ________________________     Fax Number: ______________________

Cardholder Address:_________________________________________________

                                      _________________________________________________

Company Name: _______________________________________________

Shipping Address: _______________________________________________

                                 _______________________________________________

                                 _______________________________________________

E-mail address:   ________________________________________________