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Henley Systems TelecomTelecommunications Design, Sales & Service - Est.1984Voice (318) 949-8500 Fax (318) 949-4285
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Henley Systems Telecom222 North Elm Street Haughton, Louisiana 71037 Voice 318-949-8500 Fax 318-949-4285
Date:__________________ Time:_________________ Customer Name:____________________________________ Address:__________________________________________ City:______________________________ State: _____ Zip: ___________ Telephone:_________________________ FAX______________________ Invoice No:______________ Amount $: _________________ Email Address: _______________________________________ Card Type: [ ] Mastercard [ ] Visa [ ] GSA Card Number: _________________________________ Expiration Date: _____/_____ Cardholder's Name as it appears on card:___________________________ Card Billing Address (If Different from above) _________________________ Cardholders Signature __________________________________________ Shipped VIA __________ Tracking No: __________________________ |