|
{Date:}
|
{1/1/2006}
|
|
{Order Number}
|
{00000123456 (sample)}
|
NETQUOTEDEL:DELIVERYINSTRUCTION
|
{DeliverInstructionLabel}
|
{Handle with care}
|
NETQUOTEDEL:DELIVERYINSTRUCTION
NETQUOTEDEL:PAYMENTPANEL
NETQUOTEDEL:PAYMENTSENTSEPARATE
|
{Payment Method}:
|
{Credit Card}
|
{00000123456 (sample)}
|
{Acceptable Credit Cards}:
|
{Mastercard, Visa, Switch, Switch With No Issue Number}
|
<<<{Choose One}
|
|
{Credit Card Number}:
|
______________________________________
|
|
{Credit Card Issue Number}:
|
_________
|
|
{Last three digits on Signature Strip}:
|
_________
|
|
{Credit Card Expiration Date}:
|
____________
|
|
{Credit Card Start Date}:
|
____________
|
|
{Signature:}:
|
X______________________________________
|
NETQUOTEDEL:PAYMENTSENTSEPARATE
NETQUOTEDEL:PAYMENTOTHER
|
{Payment Method}:
|
{Credit Card}
|
{00000123456 (sample)}
NETQUOTEDEL:PAYMENTCREDITCARD
|
{Credit Card}:
|
{}
|
NETQUOTEDEL:PAYMENTCREDITCARD
NETQUOTEDEL:PAYMENTOTHER
NETQUOTEDEL:PAYMENTPANEL
|
Terms and Conditions:
|
Accepted
|