Form Example 1 - Encore Electronics

Credit Card Information
16483 OLD VALLY BLVD
LA PUENTE CA 91744
Tel: 626-336-4567 Fax: 626-336-2345
Optional Extended Warranty Request Form
Authorization for credit card charges
Card Type: ________________________ Card Security Code: ______________________
Card Number: ______________________ Card Expiration Date: _____________________
Billing Information
Name on Card: __________________________________ Last Name: ___________________
Company Name (If applicable: ___________________________________________________
Address: _____________________________________________________________________
City: _________________________ State: ______________ Country: ___________________
Zip Code: ____________ Card holder E-mail: _____________________________________
Charges to be billed to the above credit card Amount $ ________________________________
Authorization
I hereby authorize Encore Electronics, Inc. to make the above charges according to the designated
frequencies listed above, and I (we) understand that all information entered on this form will be kept
strictly confidential by Encore Electronics, Inc. In the event of any unauthorized charges made on the
above credit card, I hereby agree to indemnify and hold blameless on Encore Electronics, Inc. for any an
all such charges, claims and liability related hereto. This authorization will remain in effect for the
payments listed above, and, or, until I (We) give written notice to terminate or revise it.
Signature: _________________________ Position Title: __________________________
Print Name: ________________ ___________ Date: _________________________________
For Encore Electronics, Inc. Use only!
Info verified by: _____________________
Date: ______________________________
REV 042811.1