Lawrence L. Construction Inc. Customer Fax Form
Instructions: To pay your invoice by fax, print this form, then fill out the appropriate information below. Sections including your credit card payment information need to be filled complete. Fax payments are to be submitted to 586.775.0567 Note: Fields that are in bold are required.                       Order Date:
Bill To Information MUST BE CREDIT CARD MAILING ADDRESS	Ship To Information NOT CREDIT CARD ADDRESS
- First Name:	- First Name:
- Last Name:	- Last Name:
- Email Address:	- Email Address:
- Address:	- Address:
- City:	- City:
- State:	- State:
- Zip Code:	- Zip Code:
- Phone Number:	- Phone Number:
- Fax Number:	- Fax Number:
Credit Card
- Credit Card Circle One:      Master Card   /   Visa  / American Express / Discover
- Name on Credit Card:
- Credit Card Number:
- Billing Zip Code:
- V-Code on back of card, 3 digit number:
- Credit Card Expires:
-Signature of card holder:
When Completed, Fax To 586.775.0567