Network Analysis SCS Credit Card Form

Network Analysis SCS, Inc. 119 Sunset Drive Berea, OH 44017

Phone: 440 773-4554 Fax 440 891-1025

CREDIT CARD PURCHASE AUTHORIZATION AGREEMENT

This form authorizes Network Analysis SCS, Inc. to automatically bill your credit card according to the

schedule of fees and method (s) listed below. Network Analysis SCS, Inc. is authorized to

automatically debit my credit card for all monies due it per terms of my proposal (s) / agreements (s).

CREDIT CARD BILLING: VISA Master Card Discover American Express (Circle Card)

CARD NUMBER:

EXPIRATION DATE (MM/DD/YY):

VERIFICATION # 4 digits on Back:

Bill my credit card to Ship:

from Network Analysis SCS, Inc. X in Box: [ ]Commercial Address or [ ] Residential Address

I________________________, authorize Network Analysis SCS, Inc. to charge my credit card

for charges incurred on Quoted Price / Purchase Order No.____________, which was placed by

__________________. Any credit card orders that are returned are subject to 25% restocking fee.

(Please print legibly)

Company Name:

CARD HOLDER NAME:

CARDHOLDER ADDRESS:

CARDHOLDER CITY/ST/ZIP:

CARDHOLDER PHONE:

EMAIL ADDRESS:

ITEMS TO PURCHASE:

/ / 2008

Authorized Signature Date

"This is CONFIDENTIAL Information for QuikBooks Accounting ONLY"

FAX FILLED-IN AUTHORIZATION FORM TO 440 891-1025