Telephone Order Authorization Form

TELEPHONE ORDER AUTHORIZATION

PLEASE READ CAREFULLY. A print out of this form must be filled out completely and FAXED in order for us to proceed with your telephone order.

1519 South King St., Honolulu, Hawaii 96826

Tel: (808) 951-5504 Fax: (808) 951-5135

Contact Name _____________________________________________Date__________________ P.O.#________________

Company_________________________________________________ Ph:___________________ Fax:_________________

Address_____________________________________________________________________

City___________________________________ State ______________ Zip________________

WE WISH TO ORDER THE FOLLOWING ITEM(S):
ITEM DESCRIPTION

1)_____________________________________________________Price Ea. $ ___________ Qty _____ = $___________

2)_____________________________________________________Price Ea. $ ___________ Qty _____ = $___________

SUB TOTAL $ ___________________ + TAX 4.712% $_________________ = TOTAL $_________________________

WE AGREE TO PAY THE TOTAL AMOUNT OF $__________________________. PAYMENT WILL BE MADE BY ( ) CASH ( ) CHECK ( ) CREDIT CARD
PURCHASE AUTHORIZATION BY: (Please print name)________________________________________________________________

(Sign here if paying by CASH or CHECK) SIGNATURE: ____________________________________________________________________

*IMPORTANT, PLEASE READ CAREFULLY:*
Unless you have an open credit account with Express Engraving Etc., the following credit card information will be required in order for us to proceed with your telephone order. IF YOU HAVE INDICATED PAYMENT BY CASH or CHECK, WE WILL NOT PROCESS THE CREDIT CARD PAYMENT BUT CARD INFO IS STILL REQUIRED: CARD TYPE: ( ) VISA ( ) MASTERCARD

CARD #_______________________________________________ EXP. DATE___________________ 3 Digit Security Code _____________ NAME ON CARD ______________________________________ (Sign here if paying by CREDIT CARD) SIGNATURE:________________________________________________