Capitol City Scaffolding & Equipment Company, Inc. FAX (877) 242-5995 or (615) 242-5995 - 808 Dickerson Pike

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

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Copyright © 1991-2007 Capitol City Scaffolding & Equipment Company, Inc. All rights reserved.
Services, prices, and terms subject to change without notice.

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address:

FAX (615) 242-5995 or (877) 242-5995
Capitol City Scaffolding & Equipment Co., Inc.
808 Dickerson Pike Nashville, TN 37207

Payment Form:	Cvv2# ____	Visa Card ____	MasterCard ____
Phone # of Bank issuing card (On back of card with 3 digit Cvv2#):
Credit Card #:__________/__________/__________/__________ Expires: ____ /____
Please Print Name: (As It Appears On Card)
Shipping Address: (UPS Won't Deliver to P.O. Box)


Billing Address: (Card Statements Recieved) * Same As Shipping Address___


Daytime Phone Number (Required):
FAX Number:
E-mail Address: