Steren AP-BNC-6 User Manual
116
Charge Card Application
Steren Electronics International, LLC.
6260 Sequence Drive, Suite 110
San Diego, California 92121
Tel (800) 266-3333
FAX (800) 266-3334
We accept VISA, MASTERCARD, DISCOVER and AMERICAN EXPRESS.
Company Name
Password
Street Address
Other Authorized Mailing Address
City
City
State
Zip
Telephone
FAX
Primary Charge Account Number
Exp Date
Issuing Bank
Card Type
Card Validation Code
Full Name on Card
Biling Statement Street Address
Biling Statement Street Address
City
State
Zip
Secondary Charge Account Number
Exp Date
Issuing Bank
Card Type
Card Validation Code
Full Name on Card
Biling Statement Street Address
Biling Statement Street Address
City
State
Zip
I authorize the user of the above credit card(s)
The undersigned cardholder hereby authorizes Steren Group of Companies to charge to the card account (through
signature on file) as indicated on this form, any transactions while the account is in effect. It is also noted either party may
cancel this agreement upon written notification to the other party. When calling in, you will be asked for your password as a
secondary security precaution. Any other person authorized to charge against your credit card must provide your password
to confirm authorization.
Important Information
General Information
Business Profile
Authorization
(Authorized Signature)
Date
(Authorized Signature)
Date