INVOICE

DATE: ___________________________ MYSCORE REP: _______________________________

MERCHANT ____________________________________________________________________

ADDRESS _____________________________________________________________________

CONTACT PERSON _________________________________ PHONE ______________________

WEBSITE ______________________________________________________________________

NO WEBSITE AD INFO (BUSINESS CARD, MENU, PREVIOUSLY USED AD, LOGO)

_________________________________________________________________

_________________________________________________________________

COUPON OFFER __________________________________________________________________

PAYMENT

CHECK _______________ CHECK NO _______________

CHARGE CARD INFORMATION

NAME ON CARD __________________________________________________________________

CREDIT CARD NUMBER _______________________________ CARD TYPE __________________

EXPIRATION DATE _______________________________ CSC ___________________________

MM/YY

BILLING ADDRESS LINE 1 __________________________________________________________

BILLING ADDRESS LINE 2 __________________________________________________________

(OPTIIONAL)

CITY _______________________ STATE ______________ ZIP _________________________

TELEPHONE _________________ EMAIL _____________________________________________

THANK YOU. We appreciate your business.