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Date _________________________ |
| Customer Name |
_____________________________________________________________________ |
| Street Address |
_____________________________________________________________________ |
| City*State*Zip |
_____________________________________________________________________ |
| Phone H: |
___________________________________ e-mail
____________________________ |
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| DESCRIPTION OF PURCHASE |
| Quantity |
Description |
Unit Cost |
Total |
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| Comments |
Subtotal |
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TAX |
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S&H |
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TOTAL |
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PAYMENT TYPE: CHECK
_____ MONEY ORDER ______ VISA
______ MASTERCARD _____
Make Checks Payable to:
Valiant Technologies, Inc.
For Credit Card Purchases Please
Complete Credit Card Information Below
Cardholder Name (as it appears on card)
____________________________________________________
| Credit Card Number: (VISA or
Mastercard Only) |
|
| Expiration Date ____________ |
TOTAL AMOUNT OF PURCHASE |
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| Customer Signature |
___________________________________________________________________ |
|
I agree to pay for this purchase and abide by the items of
the cardholder agreement |
|
