Graphic Specialties, Inc.

Since 1985

CONFIDENTIAL INFORMATION FORM -

DOES HEREBY AUTHORIZE GRAPHIC SPECIALTIES, INC.
                     (Name on Card)
         To charge the amount of $ to its:

Account No.   Expiration Date   CVV Code

Billing Address

City, State, Zip

Telephone No.    Fax No.

Email Address

Authorized Signatory: Dated:

Company Name:

Payment for Goods Partial Payments

Ship To:

Company Name:

Shipping Address:

City, State, Zip

Graphic must have an original signature on file. Please FAX this form to Graphic Specialties, Inc. at 1-800.741.7280

Item Number Quantity: Description:

Select Type of Payment Credit Card PayPal Check or Money Order

FAX OR EMAIL THIS FORM TO GRAPHIC SPECIALTIES, INC. WITH A COPY OF YOUR CREDIT CARD AND A COPY OF YOUR DRIVERS LICENSE

Graphic Specialties, Inc. • 10209 NW 53rd Street, Sunrise, FL 33351
1-800-815-1526 • Fax: 1-800-741-7280 • Website: www.magnets-imprint.com • Email: graphic23@bellsouth.net