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

Credit Card Guarantee of Payment

Fax back to 408-551-6882             

Date: 	___________________________	Sales Rep: ______________________

Contact:	___________________________		Phone No.: ______________________ 

Company: 	___________________________		Fax No.: ________________________

Credit card #1:	___________________________ Exp: _______ Amount _________CVV2#_____

Credit card #2:	___________________________ Exp: _______ Amount _________CVV2#_____

Credit card #3:	___________________________ Exp: _______ Amount _________CVV2#_____

Name on Card:	___________________________		  Total Amount  ___________________

Billing Address:     __________________________ Ship Address: ___________________________

                              __________________________		          ___________________________

                              __________________________		          ___________________________

                              __________________________		          ___________________________
                   
PO No.:		__________________________
	
Other Information: _________________________________________________________________

		_________________________________________________________________

	   _________________________________________________________________
	
Please authorize $ ____________________ to process PO # _______________________.

I, _____________________________, the credit card holder for the above credit card(s), agree to use the above listed credit card(s) for guarantee of payment. This credit card (or cards) is to be used to guarantee the payment of $ _____________________. 

If payment is not received within ________days as agreed, this credit card will be charged with this amount plus 3%. 

Signature: 	_________________________	  Date: ________________________
	(Card Holder)