Imaging Resources
A Division of Noops International, Inc.

Imaging Resources requires a completed authorization form in order to process a credit card order. Please complete the authorization form below and fax it and mail the original for our records. This information will be kept confidential and will help us to process all future telephone and fax orders.
CREDIT CARD AUTHORIZATION FORM
I,___________________________________ of_______________________________
(Name of Officer)
(Name of Company)
Do hereby authorize Imaging Resources to debit my credit card as Indicated:
( )VISA ( ) MASTERCARD ( ) AMERICAN EXPRESS ( ) DISCOVER
For all orders submitted.
Card Number:_________________________ Expiration Date:____________________
Name on card: ________________________________________________________________
___________________________________________________________________________
(Billing Address) (Telephone Number)
(City, State, Zip Code) (Fax Number)
SIGNED_______________________________ Dated:________________________________
Printed Name and Title:__________________________________________________________
Additional people (if any) who are authorized to enter orders with these credit cards are:
(Please give printed name and signature)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Imaging Resources reserves the right to charge an additional 3% fee if this credit card is used to pay for any invoices that are delinquent.
 
Web: ir-usa.com E. Mail: info@ir-usa.com

20315 Nordhoff Street Chatsworth, CA 91311 USA * Phone 818-727-9740 * Fax 818-998-8239
 
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