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Marktec Products, Inc. 653 Ellicott Street Batavia, NY 14020 Tel: 800-627-5832 FAX: 585-344-4109 Dear Customer, In order to process a credit card order we will need the following information. We ask that you complete this credit card application form and return it to us via fax at 585-344-4109 or mail it to the above address. Once we have received this form, we will set up a credit card account to process your orders. Address to Mail Receipt to:____________________________________________ ______________________________________________________ ______________________________________________________ Ship to Address: ________________________________________________ ______________________________________________________ ______________________________________________________ Telephone Number: ___________________________________________ Contact Person: _________________________ Extn: ________ Contact E-mail Address: ________________________________________ Please specify which method you would like to receive your receipt for charge card purchases. E-Mail ____ E-Mail Address: ______________________________ Fax ____ Fax Number: ________________________________ Mail ____ Tax Exempt: Yes________ No______ Tax Exempt Number: ____________________ If Tax Exempt, please fax a signed Tax Exempt certificate for our records. It is the responsibility of the purchaser to pay all sales and use taxes directly to their state and local governments for all shipments outside of New York and Pennsylvania. All UPS Freight charges from Factory will be prepaid and added to invoice unless you specify a freight collect account number below. Freight Collect: UPS Account Number:___________________________ Thank you for your assistance, Ms. Terry Read ([email protected]) Credit Supervisor