Credit Card Authorization Form

Credit Card Authorization Form

IMPORTANT NOTE:

You must be over 18 years old to fill out this form.

Please fax this form with your order to (775) 267-5958 (USA).

DO NOT email your credit card information.


 Date (mm/dd/yyyy):  /  / 
 
 Payment Options: 

 Charge Amount: US$ 
 
 Account No.: 

 Expiration Date (mm/yyyy):  / 
 
 Card Identification (CVV2/CID) #   THIS IS A REQUIRED FIELD. 
 CREDIT CARD MAY NOT BE APPROVED IF INVALID NUMBER IS ENTERED.

 Cardholder's name: 

 Billing Address: 

 Driver's Identification (State and Number): 

 Cardholder's Signature:_________________________________

The purchaser of OEM items shall be solely responsible to conform all finished products
to all government regulations pertaining to the manufacture and use of product; including,
but not limited to Department Health and Human Services, Food and Drug Administration,
Center for Devices and Radiological Health and Regulations, Title 21 CFR chapters.

Merchandise for return or repair shall not be accepted without R.M.A. no.
and original shipping box. All returned units are subject to a 20% restocking fee
and any additional charges resulting from product damage.

Discrepancies must be reported within 3 days from receipt.

There is no refund or replacement by any means on laser diode purchases.
INTELITE, INC.
PO BOX 774, Genoa, NV 89411, U.S.A. Tel:(775) 267-5959, Fax:(775) 267-5958