| BYRRD ENTERPRISES, INC. 1-800-628-0901; FAX 1-703-768-4086 |
| GOVERNMENT IMPACT
CREDIT CARD SALES (Please print) |
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| *NAME
OF ORGANIZATION:__________________________________________________________ |
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| FULL
NAME OF PERSON PLACING ORDER:____________________________________________ |
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| *SHIPPING ADDRESS: |
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CREDIT CARD
BILLING ADDRESS (IF DIFFERENT) |
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| * YOUR
PHONE NUMBER: ____________________ |
YOUR FAX:_______________________ |
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| YOUR EMAIL
ADDRESS:__________________________________________________ |
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*EXPIRATION |
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| *TYPE OF CREDIT
CARD |
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DATE |
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*CVV2/CVC2 |
| VISA |
MASTER |
DISCOVER |
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____/____ |
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| * CREDIT CARD NUMBER |
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* YOUR SIGNATURE (REQUIRED) |
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| *QTY |
TITLE |
PRICING INFORMATION |
TOTALS |
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SHIPPING |
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ORDER TOTAL |
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COMPLETE AND RETURN TO US AT 703-768-4086.
PLEASE BE SURE TO INCLUDE |
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CREDIT CARD CHECK NUMBER AND YOUR SIGNATURE. |
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| THANK
YOU FOR USING BYRRD ENTERPRISES. |
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