Secure Payment Fax Form

Please print this form, ensure that it is filled out completely and correctly,  then fax it to
1-440-946-4620 

I declare that this card belongs to me and authorize the charge of  

US$ __________ to my MasterCard_____Visa______

I accept to pay the balance of US$ _______ on (dd/mm/yy) ___/___/___

 Payments are credited to our US account, translated into the United States Dollar (USD) equivalent. Charges should appear on your credit card statement in your local currency based on the exchange rates and according to your card-issuers policies.  *The payee name on your statement will appear as Flex Incorporated.
Cardholders Name:
(exactly as it appears on card)		  

 
Card Number:
        -         -         -        
Expire Date:
Month: Year:
Security Code: 
 
The last three-digit number appearing on signature panel of your MasterCard or Visa
Cardholder's Billing Address:
(These details are required!)
Building:
Street:
District:
City:
State/Province:
Zip:
Country:

 
E-mail Address:  
Telephone Number:
Area code: Number:
Fax number:
Area code: Number:
Details or Service(s)   

 
by signing this form you agree to the charges above and declare that all details are correct and that this credit/charge card belongs to you.
Signature: 
(as it appears on card)		  

 

Please print this form, fill it out completely, then fax it to Flex Inc.,  (1)440-946-4620

*We charge in dollars and submit our claim, in US Dollars, to our bank. There is a delay in crediting our account (by the local bank. The overseas card issuer (via visa or MasterCard) translates the amount back into the currency chosen by the card holder. If the US$ is stronger on the day this occurs then the bill will be less than the total US$ amount billed by Flex Incorporated. It the United States Dollar currency rises in value (during the time between our submission and the time when the bank submits this to visa) then the amount will be slightly more.

 Dyna Flex Inc.

or submit Credit Application for approval