| Print and Fax to: 252-234-6010 |
| or Mail to: |
| Time and Payroll |
| P. O. Box 3442 |
| Wilson, NC 27895 |
| Billing Information | Shipping Information | ||
| Name: | Name: | ||
| Company: | Company: | ||
| Address: | Address: | ||
| City: | City: | ||
| State: | State: | ||
| Country: | Country: | ||
| Zip Code: | Zip Code: | ||
| Phone Number: | Phone Number: | ||
| Fax Number: | Fax Number: | ||
| Email: | Email: | ||
| Item: | Quantity: | Price Each: | Total Amount: |
| 1. ATR 9800 | ___________ | ___________ | |
| 2. | ___________ | ___________ | ___________ |
| 3. | ___________ | ___________ | ___________ |
| 4. | ___________ | ___________ | ___________ |
| Card Holder Name: | |||
| Card Number: | |||
| Exp Date: | |||
| Signature: | |||
| Date: | |||
| Payment Type: MasterCard[ ] Visa[ ] Discover[ ] American Express[ ] | |||