Complete Office Solutions, Inc. Credit Card Processing Form
Submission Date: ____________________
*3% processing fee will be assessed to all payments processed by credit card

Company         Customer # WH
Address            
City/State/Zip            
Phone #       Fax #    
Contact       Title    
Billing Info
Name on Card            
Address            
City/State/Zip            
Phone #       Fax #    
Card #         VC #  
Expiration mm / yy Card Type:   VisaMaster CardAmerican Express
  Discover    
Confirmation Reciepts are to be sent via:
Email Email Address:          
Fax Fax # & Contact          
           
Authorized Signature Date
           
Printed Name Title
Invoice(s) to be paid: ___________________________________
Amount to be Paid: ____________________________________
Do you authorize COS to keep credit card information on file for payments you authorize in the future?
Yes No (Credit Card information will be shredded after each transaction)
Submit completed forms to Sherry at sakimoto@cosinc.com or via fax 626-329-4811