2901 Moorpark Avenue, ste. 100, San Jose, CA 95128
          Tel: (408) 248-8811  Fax: (408) 551-6882
http://www.applied-computer.com	

Customer Charge Card Authorization
(For your protection against fraud, please complete and fax to 1-408-551-6882)

Date: ___________________

Charge Card:	Order Amount: ___________________
(for Carte Blanche, Diners Club or JCB, please add 1.5% to total order amount)

Visa             Master Card            Discover             AX                 Other: __________________________ 

Credit Card #: ____________________________________ Expiration Date: _____/_____    CVV2#: ______________

Cardholder’s Billing Information*	Credit Card Issuing Financial Institution/Bank Info*
	(Required for all international credit card)

Name ____________________________________	Name _________________________________________

Address __________________________________	Address _______________________________________

City __________________ State ______________	City ________________________  State _____________

Country _____________ Postal Code___________	Country ________________ Postal Code  ____________

Daytime Phone ____________________________	Daytime Phone _________________________________

Fax (optional) _____________________________	Fax (optional) __________________________________

Shipping Address:
(If not the same as Billing Address, Customer MUST notify bank for alternating shipping address.)

Name ___________________________________

Address _________________________________

City ___________________  State ________ Country ______________       Postal Code _________________________

Daytime Phone ___________________________    	Fax (optional) ____________________________

I, _______________________________ do hereby grant Applied Computer Online Services permission to use my above mentioned charge account information to obtain payment for my purchase. Total product amount is  $__________________ + shipping + handling fee.

______________________________	Date: _______________________
Cardholder’s Signature

Cisco Refurbished products are non-cancelable, non-returnable. If the product ordered is DOA it will be for exchange only.
* International customers are required to attach a copy of their most recent credit card statement.