Pay by Credit Card

If you do not want to transmit your information through the internet, card can be processed manually. Please print this form, fill it out manually as legibly as possible, and send it by fax 773-647-2731.
Order number, if applicable: _____________________________________
First Name: _____________________________________
Last Name: _____________________________________
Payment Type:
Card Number: _____________________________________
Expiration Date: _____ / 20____________________________
Card Verification Number: ________
Billing Address: _____________________________________
Address 2: _____________________________________
City: _____________________________________
State/Province/Region: _____________________________________
Postal Code _____________________________________
Country _____________________________________
Email Address: _____________________________________
Phone +_____(______)________________________
Order description:

_____________________________________

_____________________________________

_____________________________________

_____________________________________

_____________________________________
  We will not ship the merchandise untill your payment clears.
Amount to be charged: US$__________________________________
   

About Us

Leaders in worldwide sales of medical equipment and exclusive distributors of alternative smart cards for ACT COULTER and MELET MS in America

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