(Set Margins in browser to 0.5" or 1 cm all sides to print) - FAX TO: 1-267-295-1789

International Customers only: include readable copy of card (front & back) and the credit card statement showing your name + address. Photocopy and lighten the darkness so final copy is lighter gray for faxing or you may scan and email these. If shipping address does not match Credit Card statement please send additional verification such as phone bill, utility bill, bank statement, or government document showing your name (credit card name) and shipping address you requested. Please BLANK OUT dollar amounts or transactions on statements for privacy!

Company Name:

Date:

Name (Contact Person):

Purchase Order # (if any):

Shipping Address Street ONLY:

EMAIL ADDRESS:

City, State, Zip, Country:

Mailing (or PO box) Address **WE MUST HAVE** EXACT CREDIT CARD STATEMENT ADDRESS (if different from shipping):

City, State Zip, Country:

Phone Number:

Fax Number:

Alternate Phone (Cell or Home):

Visa / MC / AmEx / Disc (circle one) Number:

3 or 4 Digit Verification Code:
(Back of card, Front on Am/Ex)
We MUST HAVE this!

Expiration DATE:

I certify that I am a legal authorized signer on the above credit card and do authorize PrinterSmith.Com, Inc. of Boise, Idaho to charge this credit card for the items on this form and to keep this number on file for future purchases made by me or my assigns via telephone order, internet site, email, or fax. (PrinterSmith.Com GUARANTEES privacy and security of your information. Your personal information WILL NEVER BE SHARED WITH 3RD PARTIES or left on the internet.) *** CHARGES CAN APPEAR as Problem Solvers, or PAYPAL-PrinterSmith ***

Name Printed EXACTLY as it appears on Card:	YOUR SIGNATURE: x
Special Instructions or Comments:

Your Order: Please list all the information possible for each item.
Manufacturer	Model #	OEM# (if any)	Ebay/Our Stock#	Price

PrinterSmith.Com
615 E. 44th St. #7
Boise, ID 83714

1-888-465-9222
Fax 1-267-295-1789