ORDER#

DATE:

Credit Card Transaction Form Attention: GLORIA

Shipping Information (Where will we ship the item back to?) Same as Billing Address
Contact Name
Company Name
Address 1
Address 2
City State Zip
Phone Fax
Email Other
Part Number Description Price Qty Extension
70.81R26GR01 DV10 COLOR WHEEL $59.00 1 $59.00

Other Subtotal $59.00

Shipping Ground 2-Day Overnight Sales Tax (If Applicable)
Method x $12.00 $26.00 $40.00 Freight $12
TOTAL $71.00

Order processing time is 72 hrs (three business days). Part will be shipped to you ASAP. Shipping & handling
cost may vary depending on weight, qty, and special shiping requests (Sat. delivery, International, etc)

Credit Card Billing Info. (This must be filled out if anything is different from above)

Name
Company
Address 1
Address 2
City State Zip
Phone Email

Credit Card Information

Amount $71.00
Visa MC AmEx (Discover card is not accepted)
I hearby authorize Technical Service Corporation to charge my credit card

Card # Exp. Date:

Card Holder's Signature (if over $25,000) Security Code:

Name of Person (signature)
Submitting Card
(if different from the name on
the card) (print) Date:

FOR TSC INTERNAL USE ONLY: Orders over $25,000 Authorization#

Credit Manager: _________________________________________

Date: ___________________ Final Approval

CFO: __________________________________________________
Date: ___________________ Date

Senior VP: ______________________________________________

Date: ___________________

Waiver of 6 month requirement (Initial) ___________

Technical Service Corporation 715 Sycamore Drive, Milpitas, CA 95035 Tel 408-383-3700 Fax 408-383-3711