Please fill out the following information and fax the form to 323-933-0625

I , ___________________ Authorize ASIAN/EUROPEAN ELECTRONICS to charge my credit card for the purchase of the item(s) listed below.

Customer Information:

Last Name:______________ First Name:_______________ Middle Initial:______

Shipping Address: _______________________________________________________________

State: ------------------ Zip Code: ------------------

Phone: Work _________________ Home _________________________

 Card Type: VISA                                              MASTERCARD

Card Number:______________________________ Expiration Date _______________

Customer service number on back of credit card:________________________________

Please sign here to confirm your order _________________________________