After you have approved your artwork and total costs, print this form, complete ALL of the following information,

then fax it to: (316) 721-2671. Thank you.

 

Your Name:_____________________________________________________

Type of Card: (Visa, MC, Discover, AMEX)____________________________

Name on Card:__________________________________________________

Street Address:_________________________________________________

City, State, Zip:__________________________________________________

Card #:_________________________________________________________

Security Code:___________________________________________________

Expiration Date:_________________________________________________

 

The charge on your credit card will appear on your statement as Chart Marketing, Inc.