Please complete the below form to create your personalized Credit Card Authorization Form.
Your Name:
Your Fax Number:
We need this to be able to fax you back if necessary.
Your Email Address:
This form will be email to this address.
Ordering a quantity of
ARSE(s) at $_______________ each.
* Each ARSE includes 2 card keys and 1 antenna.
* Additional card keys with new ARSE are $22.00 each, at time of manufacturing.
Ordering a quantity of
additional/replacement Antenna(s) at $44 each.
Ordering a quantity of
additional Card Key(s) at $22 each, at time of manufacturing.
No
Yes
Imprint customer's supplied custom logo on card key(s) at No Charge.
Note: logos can be no larger than 150 pixels high by 226 pixels wide, 16 milion colors or less
and, a base resolution of no more than 98 pixels/inch.
Ordering a quantity of
replacement Card Key(s) at $65 each.
Ordering a quantity of
SYSTEM LIGHT CONTROLLER(s) at $_______________ each.
Ship VIA:
Ground
Red Label
Special Instructions:
Select Type Card:
Visa
Master Card
Credit Card Number:
Expiration Month:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year:
2008
2009
2010
2011
2012
2013
Credit card number can be omitted (left blank) within this form but it will need to added before affixing your signature and faxing to us.
CVV number (3 digit card code on card holder's signature line on back of card):
Card holder's name as it appears on the card:
Card Holder's Billing Address:
City, State and, ZIP code:
Phone:
Shipping Address:
City, State and, ZIP code:
Phone:
Shipping address
is a residents
is a business