Customer Information


Billing Information


Shipping Information

Shipping Carrier: Customer will be charged for freight if shipping information is not provided)
FedEx  UPS 

Tax Information

Resale Tax Exempt Yes No If Yes, Resale Number

Credit Card Information

Name on Card:
Credit Card Type: Visa MasterCard American Express Discover
Credit Card Number:
CVC2 Code: Expiration Date:

Credit Card Billing Address



By signing this form you authorize Laser Apparel to charge your card for my current orders.
If Net Terms are applied to your account, you authorize Laser Apparel to bill your credit card in full for any orders which are not paid within the net terms established.
Signature  Date 
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