Credit Card Payment Form

Please complete the following information and fax to 480-288-2000 over a secure fax line.  Your account will be credited within 48 hours.

Today's Date:__________

Vendor/Company Name:___________________________________

Type of Credit Card:  VISA  MASTERCARD (Please Circle One)

Credit Card Account Number: _________ _________ __________ _________

V-Code (Three digit code on back of the credit card.):__________

Name of Individual and/or Company on Credit Card Account

________________________________

Credit Card Expiration Date: (example 04/05 for April 2005)

Mailing address of credit card.  (This is where your credit card statements are sent:

Street Address/P.O. Box #:__________________________________________________

City:___________________State:______Zip Code:__________

Total Amount being placed on credit card at this time? $__________