Multi Cable Corporation
(860) 589-9035

Order Form

Card Holder Information: (* denotes required fields)

Company Name *
Name on Card *
Billing Address *
Address 2
Billing City *
Billing State *
Billing Zip *
Phone *
Email *

Payment Authorization

Card Type *
If 'Other' Card Type, Please Specify
Card Number *
Expiration *
Security Code *

Material Purchased

6.35% CT Sales Tax (For Residents of CT):
Total: *

Shipping Information

Ship Via *
If 'Other' Ship Method, Please Specify
Shipping Account Number (if applicable)
Estimated Shipping Charges *
Maximum Charge Allowed on Credit Card *

Digital Signature

Being the cardholder or autorized agent, by entering my name below I understand and agree to the terms set forth in this agreement, agree to pay, and specifically authorize Multi/Cable Corp. to charge my credit card for above purchase. I further agree that if my credit card becomes invalid I will provide a new valid card upon request, to be charged for any outstanding balance to my account.

Your Name *