AUTHORIZED SIGNATURE
FOR PRICE/AMOUNT DUE AND PAYMENT METHOD USED (i.e., Credit Card, Check,
PO# ):_________________________________________________________________________
I AGREE TO PAY THE ABOVE TOTAL
AMOUNT ACCORDING TO THE CARD ISSUER AGREEMENT FOR THE
LISTED/INPUTTED CLIENT CREDIT CARD AND/OR FOR THE PURCHASE NUMBER
(PO#) LISTED. ALL SALES ARE FINAL. NO
REFUNDS. I AGREE TO ALL GUIDELINES, NDAs, POLICIES,
AND PROCEDURES OF COMMBASE TECHNICAL SOLUTIONS, LLC AND EXECUTED CONTRACTS WITH COMMBASE TECHNICAL SOLUTIONS, LLC PRIOR
TO ANY SERIVCES OR PRODUCTS PURCHASED. I AGREE TO PAY FOR THE ABOVE RENEWAL PRICE ABOVE ACCORDING TO THE CARD ISSUER AGREEMENT FOR THE ABOVE LISTED CREDIT CARD FOR THE RENEWAL PURCHASE PRICE TO RENEW THE SERVICES AND LICENSE/PRODUCT STATED ABOVE. UPON ME CLICKING ON THE "PAY NOW" BUTTON BELOW", I AGREE TO ALL THE ABOVE STATEMENTS AND I AUTHORIZE AND APPROVE MY DIGITAL SIGNATURE TO BE ENTERED HERE AND ON THE NEXT PAGE AFTER I CLICK THE "SUBMIT" BUTTON.
Service Date Scheduled/Requested:___________ Service Time Scheduled/Requested:___________ Payment Confirmed :____________
Receipt#:_________________Email Confirmation Sent;_____
CLIENT NAME:___________________________________
BILLING ADDRESS:____________________________________________________
TELEPHONE#:_________________________
CELL#:______________________
FAX#:_________________________
E-MAIL(Billing):____________________________________ E-MAIL(Notifications):_________________________________________
COMPANY NAME: __________________________________________ADDRESS:_______________________________________________________
TELEPHONE#:__________________________
CELL#:______________________
FAX#:__________________________
E-MAIL(Billing):____________________________________ E-MAIL(Notifications):_________________________________________
(Internal
Use Only)
Payment
& Registration Processed: Fax Order_____ Telephone Order_____
e-Commerce_____
Marketing
Representative ID#:______________________ Telephone#:________________
Cell#:________________ Email:_____________________
WO#:____________
Date Completed:_______________ Approved
Spiff/ID#:_________________
| Cash:
Yes___ No____ |
Amount
Paid :______________________________ |
| Check: Bank_____
Personal____ Business____ |
Check
# ____________________ |
DL#____________________ (optional) |
Expiration____________ |
State:_________ |
| Credit
Card Used (selct one): Visa:________________/Exp:_________ MC: ________________/Exp:__________ Discover:________________/Exp: _________ AMEX: _______________/Exp: ________ JCB:________________/Exp:__________ Debit (Visa)___________________/Exp:____________ Debit (MC)_____________________/Exp______________ ( CVV_______ ) |
| P.O.
#:_______________________________________________________________ |
Gift
Certificate #:_______________________________________________________ |
CommBase
Technical Solutions, LLC |
Attn: Sales Departent / Technical Services Departmnt |
109 E. 17th Street * Suite 5089 * Cheyenne, WY * 82001 |
Tel: (307) 773-0124, ext. 1003 * Fax: (877) 335-0603 * Email: e-sales@commbasetech.com |
