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Billing Address
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Name
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Company
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Address
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City
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State
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Country
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Zip
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E-mail
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Tel
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Shipping Address
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Check if same as billing address |
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Name
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Company
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Address
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City
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State
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Country
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Zip
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E-mail
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Tel
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Special Shipping Instructions
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Credit Card
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Credit Card
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Exp. Date
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Card Number
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**ID
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Cardholder
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Total Credit Card Debit Amount in US$ (including 5% surcharge)
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*For all credit card payments, there is a 5% surcharge over the Purchase Order Total
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I Authorize Synergy Tecnologia em Sistemas Ltda to charge my credit card the Total Amount specified in this Authorization Form for
the payment of products I am ordering in this Purchase Order.
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Date
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Cardholder’s Signature
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