Verification & Confidentiality Form

The information below is required to process all orders that are received by C.B.S. / Copperstate Business Services, Inc. (hereinafter known as C.B.S.).  This information is necessary for our Customer's, Check Writer's, Credit Card Holder's and C.B.S.'s protection.  All Customer and/or Check Writer/Credit card holder's (if different than Customer) must provide the information below for the product(s) you/they have ordered via Telephone, Fax, Mail and/or Email.  C.B.S. keeps all Customer, Check Writer and Credit Card Holder's personal information strictly confidential.  C.B.S. "does not" sell or release in any way any personal information to any Person, Company or any other Entity without the written permission of our Customer, Check Writer and/or Credit Card Holder's.

"C.B.S. Values and Honors Our Customer's Privacy and Trust"

Verification Method Used:         Telephone              Fax              Internet / E-mail

           (Please Circle One)

Customer's Social Security Number: _____-_____-_____  Customer's Date of Birth:____/_____/____

Customer's Drivers License Number: ____________________ State:____Exp. Date: ____/____/____

Check Writer's Social Security Number: ____-____-____ Check Writer's Date of Birth:____/___/____

Check Writer's Driver's License Number: _________________State:____Exp. Date: ____/____/____

Customer's E-mail Address: _______________________________@________________________

Check Writer's E-mail Address: ____________________________@________________________

Order taken by:______________________________________Date Order Placed: ____/____/____                     

                                  (Name of Person at C.B.S. who took your order)

Payment Method Used:   Personal Check     Business Check    Credit Card: ____________________

     (Please Circle One)                                                                             (Credit card used - i.e. VISA, M/C, AMEX, Discover)                              

If paid by Credit Card:  ____________________________________________________________

                                                                         (Full Name on Card)

If by paid Credit Card: ______________________/__________________________/_________

                                          (16-Digit Account Number)        (The 3 or 4 digit personal code located on back of card)    (Exp. Date on Card)

All orders processed via fax or mail require the Customer and the Check writer/Credit cardholder's signature.

(If the Customer and the Check writer/Credit card holder areone in the same, then only one signature is required below)

(I/We understand that all sales are final and no refunds will be issued) (I/We hereby authorize C.B.S. to charge the ordered items to the above listed charge card(s)

 

X_________________________        X_______________________________________

                (Customer's Signature)                         (Check writer/Credit cardholder's signature  (If different than Customer)                                   

                                                                        

Page 2 of 2