Order Form

Object Image, replacement for Object that CuteSITE Builder was unable to create from RTF.

40 Franklin Street

Needham MA 02494

(781) 449-1005

Fax (781) 449-1009

PRE-AUTHORIZED CHARGE CARD ORDER FORM

NAME: (as it appears on your card)________________________________________________

CREDIT CARD TYPE: MasterCard Visa AMX Discover (circle one)

CREDIT CARD #:_______________________________________EXPIRATION DATE________

I____________________________________________________AUTHORIZE $____________________

(SIGNATURE)

TO BE CHARGED TO MY CREDIT CARD ON__________________________________

(DATE)

THIS CARD IS BILLED TO:

NAME:______________________________________________________________________________________

ADDRESS:___________________________________________________________________________________

(Street, City, State, & Zip Code)

PHONE NUMBER: __________________________________________________________________________

We will need to contact the card holder for the Security Code from the Credit card in order to Process the Order. The Security code should not be E-mailed or Faxed as the Security Code could be compromised. For Faster Service you may want to contact our sales staff (781-449-1005) after faxing this form to expedite the process.

CHECK HERE IF PRODUCT IS TO BE SHIPPED.

CHECK HERE IF PRODUCT IS TO BE PICKED UP.

CHECK HERE IF SOMEONE OTHER THAN THE CARDHOLDER WILL BE PICKING UP THE ORDER. PERSONS NAME:_______________________________________________________________

PLEASE PROVIDE A BRIEF DESCRIPTION OF PRODUCT ORDERED BELOW:

_______________________________________________________________________________