Datasheet

116
Charge Card Application
Steren Electronics International, LLC.
6260 Sequence Drive, Suite 110
San Diego, California 92121
Tel [phone]
FAX [phone]
We accept VISA, MASTERCARD, DISCOVER and AMERICAN EXPRESS.
Company Name Password
Street Address
Other Authorized Mailing Address
City State Zip
Telephone FAX
Primary Charge Account Number Exp Date
Issuing Bank Card Type Card Validation Code
Full Name on Card
Biling Statement Street Address
City State Zip
Secondary Charge Account Number Exp Date
Issuing Bank Card Type Card Validation Code
Full Name on Card
Biling Statement Street Address
City State Zip
I authorize the user of the above credit card(s)
The undersigned cardholder hereby authorizes Steren Group of Companies to charge to the card account (through
signature on file) as indicated on this form, any transactions while the account is in effect. It is also noted either party may
cancel this agreement upon written notification to the other party. When calling in, you will be asked for your password as a
secondary security precaution. Any other person authorized to charge against your credit card must provide your password
to confirm authorization.
Important Information
General Information
Business Profile
Authorization
(Authorized Signature) Date
(Authorized Signature) Date