Credit Card Payment Form 1

Computer Sales and Service's PAYMENT CENTER
MAKE ONE-TIME CREDIT CARD PAYMENT HERE

INSTRUCTIONS: to render payment, please fill in this form and press "register payment",
all fields marked with a red star are required. home>

CARDHOLDER'S INFORMATION

I am the named CARDHOLDER:

* Cardholder's Name   must match card billing name.

* My Email Address: (format: name@domain.com, e.g.- BenFranklin@USMint.gov)
* Reconfirm Email Address: (enter it a second time to confirm)

CARD INFORMATION

Hereby do AUTHORIZE and PERSONALLY GUARANTEE that Computer Sales & Service may charge my credit card:

* My Card is a: MasterCard | Visa | AMEX**¹ | JCB | Discover | Gov't Purchase Card (MPAC)
                                   Note 1: We do not presently process American Express.
* My Credit Card Number is: no spaces please
* It's Expiration Date is:   mm/dd/yyyy or mm/yyyy
    It's SSC/CVV2 Security Number (optional): (usually found on reverse of card on white strip after card number)

* Credit Card Billing (Personal) Address:

    (NOTE: Address must be verifiable through the Credit Card Company or AVS)

    EMPLOYER'S INFORMATION (optional)
    Company Name: (optional)
        Type of Company (optional):Corporation | LLC | Partnership |Proprietorship | Other
        State/Country of Organization (optional): Date organized:
        Employer's Address (optional):


* Cardholder's Phone Numbers & Points of Contact
    *Day:   *Night:
      Cell: (optional)

CHARGE AMOUNT(s)

The AMOUNT OF the (US Currency ONLY) charge is:

* Sales Dollar Amount $    US $xxx.xx
    Plus SALES TAX      $    (If sales tax is required, we will calculate it and add it on for you.)

* Plus Computer Sales & Service may charge me for FREIGHT for shipping/handling by:
    Slowest (UPS Ground / Fedex Ground, Cont'l US ONLY)
    Fastest (Overnight, Cont'l US ONLY)
    Other (International or Other)

PURCHASE INFORMATION

    * A Brief Description of the purchased merchandise and/or comments (brief description or cut/paste page):

    (the above may be omitted, or will be updated/filled in by Computer Sales & Service)

The optional SHIP TO Address (must be VERIFIABLE THROUGH THE CREDIT CARD BANK, or been previously
registered directly through CUSTOMER SERVICE 908-931-1200).

    Optional SHIP TO Location


Please note: all Ship To addresses are confirmed with your Credit Card Bank, no orders will be fulfilled
to any Ship To address which your Credit Card Bank does not verify. Alternate Payment Methods include:
PayPal, Western Union, Western Union Quick Pay, Wired Funds Interbank, MoneyGram, Certified Check
(verified by payor bank), Money Orders (verified by issuing company), cash under $5000.

AUTHORIZATION & LEGAL SIGNATURE SUBMISSION

I authorize Computer Sales & Service to charge my above Credit Card in the amount indicated, plus any freight/handling,
and any additional charge that may be authorized by me or owed by me. I understand and agree to be bound by
Computer Sales & Service's standard terms and conditions of sale. I shall obtain Computer Sales & Service's express permission
in regards to and prior to all subsequent actions I undertake in all billing issues and/or obligations connected with
this transaction. This transaction shall be subject to the General Business Laws of the State of New Jersey, and
the laws of the United States of America (in that order) in all matters of law. I certify that I am the authorized
cardholder of said credit card, I am of age and permitted to enter into this agreement. Computer Sales & Service is
hereby authorized to investigate and ascertain the credit worthiness of this transaction as it deems necessary.
By checking the "AGREED" checkbox below and by re-entering my name a second time and today's date, I
hereby confirm and acknowledge this transaction and agree to be bound by it.

* AGREED: * Name (must match CARDHOLDER's NAME): *Today's Date:

* Please press the appropriate button:        top of form >    |    home >