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| TED Components |
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601 Galahad Drive, Unit # 8;
Oshawa Ontario L1K 1L19, Canada |
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| " Confidential Visa/Mastercard
information/contract of Purchase" |
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| Name: |
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| Address: |
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| Tel: |
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| Fax: |
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| email: |
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| Card
Home Bank: |
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| Visa/Mast.
Number: |
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| Expiry: |
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| Name: |
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| Amount
authorized : |
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| Special
instructions |
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| By
filling out this statement, I authorize TED Components to debit my credit
card in the amount |
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above. Failure to complete the transaction will result in legal actions to
recover the |
| cost of goods and services delivered and the
cost of expediting the said amount indicated above. |
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| I agree: |
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| Sample
signature: |
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