Your Full Name (Please Print)
__________________________________________________
Address
______________________________________________________________________
______________________________________________________________________________
City ________________________________________
State ________________________________
Zip Code_____________________________
Telephone ___________________________
Fax__________________________________
Email_________________________________
PAYMENT (in full):
Michael, I agree that I am the rightful credit card holder placing
this order and I agree for JS&M Sales And Marketing to charge my credit
card number above for
(Please
write in the amount)
$___________
SIGNATURE
X_________________________Date__________2010
I
understand that the charge will be made by JS&M Sales and Marketing Inc.
1) Your name as it appears on your credit card
___________________________________________________
2) Your credit card number
__________________________________________________________
3) The expiration date
___________________________________________________
4) Your BILLING address for that credit card
____________________________________________________
5) The 'security code from your credit card
_______________________
a) If using Visa or MasterCard, the 'security code' are the last
three digits on the BACK of your credit card in your signature panel
b) If using American Express, the 'security code' are the four
digits on the FRONT of your credit card above your credit card number
6) The shipping address where you want products shipped
____________________________________________________________
____________________________________________________________
7) Phone number
____________________________________________________________
8) e-mail address
____________________________________________________________
Please make sure you sign the part in yellow and e-mail or fax
everything back to me to 858-274-2579