TROY Group Digital Imaging Order Form - Manual (Page 3)

Digital Imaging Order Form
Document #11-19295-001 Rev. R Page 3
Section B: Billing and Authorization Form
Billing Address
Company Name __________ _________________________________PO# ___________________________
Address ______________ ________________________City________________ State ______ ZIP___________
Attention _____ ________________________________________ Telephone __________________________
Shipping Address
(if different from billing address)
Company Name __________ _________________________________PO# ___________________________
Address ______________ ________________________City________________ State ______ ZIP___________
Attention _____ ________________________________________ Telephone __________________________
E-Mail address____________ _________________________________
All orders will be shipped UPS ground unless otherwise specified. Please note your preference below:
SHIP VIA: _________________ _______________ FREIGHT ACCT# (Optional) __________________________
Signature Authorization (must be completed to process order)
Payment Information (If buying through a Reseller Net 30 credit account only notes Reseller and PO #)
Major credit cards accepted (Please circle one): VISA MASTERCARD AMERICAN EXPRESS
CC#_____________________ ________________EXP. Date: _________________ SEC CODE: _________
______________________________________ ____ ______ __________________________________
Cardholder’s Name (Please Print) Cardholder’s Signature
Billing Address of Credit Card ____________________________________________________________ __
Authorizing Signature Date __________________
Authorizing Name (please print) _________ __ ____________________________________________
Title ______________________ ___________ Company ________ _________________ ___________
I hereby authorize the signatures(s) appearing on the TROY Signature Form (Section D), to be digitally imaged for use on digital
printing equipment. Attached are the actual signature(s) from Section D and any other original logo/graphic image(s) as
designated on the Logo/Graphic Mounting Form (Section x) to be digitized. The programmed image device(s) (CARD, DIMM, or
Serial Bus), including any additional programming information (when appropriate), will be delivered to an alternate address if
provided above.