Credit Card Authorization

592 Apollo Street, Brea, CA 92821 Sales: (714) 990-2300 Fax: (714) 990-3303

CREDIT CARD AUTHORIZATION

ALT009624

ALTINEX - END USER NAT'L

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 fill out the form completely and accurately. We reserve the right to verify the provided information with your Credit Card issuing bank. We are not responsible for delays due to missing or improper information.

Name On Card

Type of Card

Visa MasterCard American Express Discover

Credit Card Number

CVV Number

Expiration Date

Credit Card Billing Address

City

State/Province

Zip Code

Country

This is a Personal Credit Card and I am authorizing to charge it for the purpose of a company purchase.

I authorize Altinex, Inc. to charge this credit card only for a specific order.

I authorize Altinex Inc to charge this credit card for current and future transactions until requested in writing to stop or an open credit limit has been established.

Special Comments:

I, the undersigned, understand the credit card authorization policy and hereby authorize to charge my credit card for product(s) purchased. For customers with terms, such as Net 30, the payment with a credit card after product is shipped with incur a 3.5% service fee. I represent that the information provided in this authorization is accurate, that the credit card is valid, and it will not be declined. I agree to be bound by applicable policies, terms and conditions, and instructions for this transaction.

Name of Card Holder

Date

(Version 12/2/15)