Translation

Att: Mr. David Menson
e-mail: dmenson@colba.net
 
Dear Mr.. Menson,
 
To ship your Order for
Item Number: Z-WISC-1941X-N
Sterilizers.com Price: $543.22
 
I need your
 
Company Name:
 
Shipping Address:
 
 
Phone Number
 
To Charge your credit card please complete and Fax this Authorization Form:
 
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To: ALFA Medical Equipment Factory/Headquarters
Att: Joe Malpiedi     
59 Madison Avenue     
Hempstead, NY 11550
ALFA Fax:                              1-516-489-9364
ALFA International Phone:                    1-516-489-3855 ext 241
Email                                   jm@sterilizers.com
24 Hour Emergency Service                    1-516-314-5600
Interactive Website                         wwwsterilizers.com
                    
Authorization to Charge Credit Card as Marked in Box [ ]
VISA [ ]        MASTER~CARD [ ]            DISCOVER [ ]       AMERICAN~EXPRESS [ ]                                                                                                                                                                                                                                                                                                                                                                                                    
Credit Card Information:
Cardholder Name: ___________________________________________________________ Cardholder Address:__________________________________________________________ ______________________________________________________________________________________________________________________________________________________
This Card is Authorized for Purchase Order(s) _____&_____&_____&_____&_____&____
This Card is Authorized for All Future Purchase Orders          Yes  [  ]        No  [  ]
Purchase Amount Authorized in U.S. Dollars: _____________________________________
Shipping Amount Authorized in U.S. Dollars: _____________________________________
Additional Amount Authorized in U.S. Dollars:________________ Reason: _____________
Total Amount Authorized in U.S. Dollars: ___________________________________
Credit Card Number:  ___  ___  ___  ___ --- ___  ___  ___  ___ --- ___  ___  ___  ___ --- ___  ___  ___  
Expiration Date:  ________________ /// ________________
                    Month                    Year
The 800 # of the Bank on the Back of the Card is: ___  ___  ___ --___  ___  ___ --___  ___  ___
CVV2 or CVV2 Digital # [____________] This is the last 3 digital number on the backside of my card.
IF NEEDED~~~My American~Express Card Security Code # is_______________________
Comments: _________________________________________________________________
___________________________________________________________________________
~I hereby authorize Alfa Medical to charge the above card account for the amounts shown~
 
 
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Authorized Signature                         Title                    Signature Date
~I hereby authorize Alfa Medical to charge the above card account for the amounts shown~
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Thank you for choosing ALFA,