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eBay Item Number(s):

 

Amount for Item(s):

 

Amount for Shipping:

 

TOTAL You Are Paying:

 

Circle One:  Mastercard     VISA     Amex     Discover

 

Credit Card Number:

 

C V V:

 

Expiration Date:

 

Name as it appears on the card:

 

Billing Address:

 

Billing City, State, Zip, Country:

 

Billing Phone Number:

 

Shipping Address (if different from Billing Address):

 

Shipping City, State, Zip, Country (if different from Billing Address):

 

E-Mail Address: 

 

 

 

__________________________________________________________________________

Signature of Authorized Card Holder Authorizing Payment As Described Above

 

Complete and fax this form to 405-354-4105, or

Complete this from, scan it, and e-mail it to paypal@smecs.info

 

_____  Check here if this is a GIFT going directly to the Recipient; We will not include a packing slip

 

OTHER  SPECIAL INSTRUCTIONS FOR THIS SHIPMENT from Buyer to Seller: