I_________________________________authorize Capital Data, Inc. to
(name printed)

charge my credit card # ___________________________________________

expiration date________ SEC#______ in the amount of $____________US.

Equipment to be purchased:_________________________________________

___________________________________________________________________

I understand freight charges will also be charged to my card and

the above amount referenced is for goods only. Import duties/taxes

will be billed collect if possible, otherwise they will also be

billed to my credit card. I understand Capital Data will only ship

to the verified address on record for your credit card. My

credit card billing address is:___________________________________

__________________________________________________________________

__________________________________________________________________.

I understand that I am responsible for all import duties, taxes and

freight associated with this order. It is also understood that

once the product has shipped, should I change my mind regarding

this purchase or wish to return the product for other than

defective, a 35% restock fee will be assessed and will be deducted

from the credit to my card. Products have 30 day warranty.

__________________________________________ _________________

(Signature) (Date)

**Customer Phone# ____________________________________

(Please include country code if you know it.)

Customer Fax#_________________________________________

Customer Email Address:_______________________________

*******A PHOTOCOPY OF YOUR CREDIT CARD (FRONT AND BACK) IS REQUIRED
ALONG WITH A COPY OF YOUR DRIVER'S LICENSE. REV.04/08