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500 Jefferson Street, Placentia, CA 92870
Sales: (714) 990-2300 Fax: (714) 990-3303
Visit Us: @www.altinex.com

Your completion of this authorization form will help us to protect you, our valued customer, from credit card fraud. All information entered on this form will be kept strictly confidential. Please complete the form below.

Directions:

If you have any questions please call accounting at 714-989-2167. Thank you.

Fill out this form completely. Credit card holder must digitally sign on the line indicated. We reserve the right to verify the provided information with your Credit Card issuing bank.

I understand credit card authorization policy and hereby authorize to charge my credit card for the product(s) purchased. For customers with terms such as Net 30, the payment with a credit card after the product is shipped will incur a 3.5% service fee.

I represent that the information provided in this Authorization is accurate, that the credit card is valid, and will not be declined.

I agree to be bound by applicable policies, terms and conditions, and instructions for this transaction.