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USA EUROPE JAPAN BRAZIL ARGENTINA

11124 Washington Blvd., Culver City, California U.S.A. 90232 Phone: +310 280-9620 Fax: +310 838-7294 Email: sales@u ninetimaging.com
www.uninetimaging.com
Absolute COLOR Absolute BLACK UniDrums UniRollers UniParts UniCoatings
Yes, I authorize UniNet Imaging, Inc. to charge all orders shipped to the addresses listed on this appli-
cation to my credit card:
Credit Card Account #: Exp. Date:
Select Type: ( ) Visa ( ) MasterCard ( ) AMEX 4-Digit Code:
IMPORTANT! You MUST complete this portion in order to process your order.
Cardholder Information
Name (as it appears on credit card):
Billing Street Address:
: e c n i v o r P r o e t a t S : y t i C
: y r t n u o C : e d o C l a t s o P
Credit Limit:
Company Information
: r e b m u N D I t n u o c c A : e m a N y n a p m o C
Contact Person:
: ) t n a t r o p m I ( x a F : ) t n a t r o p m I ( e n o h p e l e T
Ship to Street Address:
: e c n i v o r P r o e t a t S : y t i C
: y r t n u o C : e d o C l a t s o P
I will be purchasing computer, copier, laser parts, and printing supplies from UniNet Imaging, Inc. under the
business terms published.
e t a D e r u t a n g i S r e d l o h d r a C
Credit Card Authorization
FAX TO: (310) 838-7294
NOTE: All Credit Card Authorization forms must be submitted to the accounting office during
normal business hours prior to 2:00 pm Pacific Standard Time. Any Credit Card Authorization
forms submited AFTER this time will be processed on the NEXT business day.
5546 2930 0117 6289
Jos Roberto Cortes Vargas
Glorieta de Coln 169
Glorieta de Coln 169
INSUREM
Mr. Jos Luis Snchez
0155 65 88 41 77
Nezahualcytl
Nezahualcytl
Estado de Mxico
Estado de Mxico
30 MAYO 2014
57700
57700
Mxico
Mxico
14,100.00 MXN
07 / 19
169
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