ALX Imaging, LLC - Credit Card Authorization Form

	Net 20 Payment Terms Agreement
	Please print and fill out completely, and email it to sales@alximaging.com

Company Billing Information:

Company/Name:	Phone Number:
Address:	City/State:
Suite/Rm/Floor:	Postal Code:
Attn Contact:	A/P Fax Number:

Select Here: Corporation, Date Inc.______, State Inc.___ Partnership Proprietorship L.L.C Non-Profit

Company Shipping Information:

Company/Name:	ShipTo Attn:
Address:	Estimated Monthly Purchases:
Suite/Rm/Floor:	Multiple Shipping Locations: YES NO
City/State/Zip:	Is a Purchase Order Required? YES NO

Credit Card Information:

Please select one: Visa MasterCard Discover AMEX

Credit Card Number:

Expiration Date:

Name(s) on Credit Card:	3 Digit CVV Code:
C/C Billing Address:	Zip Code:
C/C City/State:	Tel No:

Terms & Conditions of Sale: (Please read and understand before signing)

I, the undersigned, agree to pay for all purchases according to the terms & conditions as they appear on the most current web site at ALX Imaging, LLC. If credit is extended, I/we agree to pay all debts incurred within the terms of sale. The undersigned agrees to the continued solvency of the Credit Card as a precondition to any sales made by ALX Imaging, LLC . No terms or conditions of purchase orders different from the terms of ALX Imaging, LLC will become part of the Sales Agreement. However, if the debt should become past due. I/we expressly agree to give ALX Imaging, LLC permission to apply the full remaining balance, plus 7% of said balance (to cover credit card and other processing fees), as well as any current or future purchases, to the beforementioned Credit Card. I/we also agree to authorize ALX Imaging, LLC to verify the validity of the beforementioned Credit Card from time to time.
If I/we purchase and do not return in a timely manner, any products that require an exchange within 20 days, I/we agree to become liable for the difference in price between the exchange and non-exchange prices, plus a per cartridge late fee of $10.00 and/or per fuser unit late fee of $20.00 after 30 days from ship date.
The laws of the State of Texas shall be applicable to all suits arising under any agreement between the undersigned and ALX Imaging, LLC . In the event of litigation, venue shall be the choice of ALX Imaging, LLC . I/we further agree to pay reasonable collection costs and attorney's fees incurred by ALX Imaging, LLC to collect any outstanding balances.
I understand that, with my signature, I acknowledge that I have checked all information provided to ALX Imaging, LLC and it is correct, and that I have read, understand and agree to all the terms and conditions, and a minimum annual volume requirement is $3,000 net sales.

Cardholder Signature:

Date: