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Credit Card Payment Please print this page, fill in the information and fax it to AMC 1. Credit card type Master Card________ OR Visa__________ 2. Credit Card ________________ OR Debit Card______________ 3. Credit Card Number ____________________________________________________________ 4. Name as it appears on the card __________________________________________________ 5. Expiration Date Month_________ Year_____________ 6. Three Digit Code on the back of the Card __________________ 7. Billing Address for the card _________________________________________________________ _________________________________________________________ _________________________________________________________ _____________________________________Zip__________________ 8. Phone Number _________________________________________ 9. Charges will be for engineering time plus expenses that may include administrative fees. All Charges will be in US Dollars. There are NO refunds for time spent, work in progress, or minimum charges. If the client requests a stop work AMC will endeavor to reduce additional expenses. AMC is Authorized to proceed not to exceed $_______________________________ Signature_______________________________________ Date_____________________________ __________________________________________________________________________________ __________________________________________________________________________________ FAX completed form to 425-962-2959 Contact Information:
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