Rush PCB - Credit Card Authorization Form

Date

Job #

Part #

Company’s Name

Shipping Address

Telephone Number

Payment Method

Purchase Order

Credit Card

Credit Card Type

MasterCard

Visa

American Express

Discover Card

Name as it appears on card

Billing Address (Credit Card)

Credit Card #

Expiration Date

Security Code (on the back of the card):

Job Value

Job Qty

Job Lead Time

Signature of cardholder Clear

Date

Title/Relationship if other than customer

* UPS/FedEx Account or Prepay and Add?

** Please specify shipping method:

Please Specify Shipping Service (Overnight, 2Day, Saver or GND):

CA Customers (Taxable or Non-Taxable):

*** CA Seller’s Permit Number:

(For orders shipping within or to California. Must provide a signed CA Resale Certificate Form otherwise all orders will be taxable.)

~CREDIT CARD AGREEMENT~ * This credit card charge is intended for the sole purpose of paying for electronics components (printed circuit boards, parts, and assembly labor). ** A 3% Credit Card Processing Fee will be applied to all credit card transactions. *** Client agrees to Rush PCB charging 50% deposit of the job value at the time of placing a Turnkey project, and the balance amount to be charged at time of completion. **** By submitting this form, you are acknowledging intent to proceed with this transaction.