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Billing Name: ________________________________________________________

Billing Address: _______________________________________________________

City: ________________________________, State: _____

Postal Code: ________________, Country: __________________

Telephone Number:_____________________ Fax Number: ___________________________

Card Number: ___ ___ ___ ___ — ___ ___ ___ ___ — ___ ___ ___ ___ — ___ ___ ___ ___

Expiration Date  ___ ___ / ___ ___ (mm/yy)    CV2 Code ___ ___ ___  

I do hereby authorize Custom-PC Computers LLC

to charge the amount of $_____________ to

 the above Credit Card Account for ____________________________________________.

Invoice #_________________

Signature: ___________________________________, Date: _________________