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
Company:  __________________________________________
Contact:  __________________________________________
Ship to Address:  __________________________________________
City:  __________________________________________
State: 
_______________________Zip:________________
Phone Number:  __________________________________________
Email Address:  __________________________________________
Purchase Order #:  __________________________________________
Product Ordered:  __________________________________________


 Credit Card Information

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