Credit Card Authorization Form printable pdf download

Credit Card Authorization

Please fax the completed form to:

Canfield Imaging Systems

(973) 575-9914

Canfield Imaging Systems has initiated this procedure to protect both Canfield Imaging Systems and its customers from credit

card fraud. The purpose of this form is to prevent an unauthorized purchase of product with your credit card and having the

product shipped to a fraudulent address.

Please be advised that all of the fields listed below are required. If any are blank, the payment form will be returned to you.

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CREDIT CARD INFORMATION

(Visa, Master Card, and American Express accepted.)

Name (As it appears on credit card): __________________________________________________________

Credit Card Number: ______________________________________ Expiration Date: ________/________

Security ID Code (found on back of Visa-Master Card / Front of AmEx Card) _______________________

Cardholder Signature: _____________________________________________________________________

Payment Amount: __________________________

CREDIT CARD BILLING INFORMATION

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The following information is required. Please be advised that if the information you provided is incorrect, the transaction will

not be approved.

E-Mail Address: ______________________________

(Please provide if you wish to have your transaction receipt e-mailed)

Address: _________________________________________________________________________________

_________________________________________________________________________________

City:

___________________________________________ State: _______________ Zip: _____________

Return / Exchange Policy

Product returns after 15 days from date of delivery are subject to a 15% re-stocking fee. No returns will be accepted on digital equipment after 15 days

from the date of delivery or on other hardware or software. Special Order items, including computers, are not returnable. Original shipping costs are

subject to a 5% service

non-refundable. All refunds are processed via company check. If customer requires refund via credit card, the transaction is

charge.

To return any items you must call Customer Service for prior approval and obtain an RMA Number. Items can be returned only if in original

packaging, unused condition, with literature/instructions and blank warranty cards. Place the manufacturer’s box into a shipping box. Please do not put

any stickers or labels on the original manufacturer’s packaging. Please ship the items back to us prepaid. For your protection, make sure to insure the

packaging. Canfield Imaging Systems cannot be responsible for lost or damaged packages.

NO RETURNS WILL BE ACCEPTED WITHOUT AN RMA NUMBER

If any of the above conditions are not met, Canfield Imaging Systems reserves the right to refuse the return.

DATE: ___________________

QUOTE #: ______________