Credit Card Fax Form Please print this Credit Card Form then fill in the information and fax to: D.C. Helms, Inc. - Fax: 908-859-4414 Back 561 Memorial Pky. / Phillipsburg, NJ 08865 / 908-859-2000 / Fax: 908-859-4414  Order Information *****This is not working yet! It will be working shortly! Company:  __________________________________________ Contact:  __________________________________________ Ship to Address:  __________________________________________ City:  __________________________________________ State:  _______________________Zip:________________ Phone Number:  __________________________________________ Email Address:  __________________________________________ Purchase Order #:  __________________________________________ Product Ordered:  __________________________________________  Credit Card Information *****This is not working yet! It will be working shortly! Type of Credit Card:  Master Card  Visa Card  Discover Card  American Express                                      Credit Card Number:  __________-__________-__________-__________ Credit Card Verification #:    Where is this number ?       ____________ Credit Card Expiration:  ________________ (Date). Name On Credit Card:  __________________________________________ CC Billing Address:  __________________________________________ City:  __________________________________________ State:  _______________________Zip:________________ Signiture:  __________________________________________ Date:  _______________________ Please print this Form then fill in the information and fax to: D.C. Helms, Inc. - 908-859-4414 D.C. Helms, Inc. will call and verify the information. E-mail D.C. Helms, Inc. 561 Memorial Parkway Phillipsburg, New Jersey 08865 908-859-2000 / Fax: 908-859-4414