UNITED STATES DEPARTMENT OF THE
INTERIOR
BUREAU OF LAND MANAGEMENT
NIFC GREAT BASIN AREA CACHE
3833 S. DEVELOPMENT AVE.
BOISE, ID
83705
FAX NUMBER
(208)387-5573
CREDIT CARD INFORMATION (MAIL OR FAX WITH
ORDER)
To protect credit card
information,
please complete the
following information
and submit with
the
copy of your order. DO NOT PUT CREDIT CARD INFORMATION ON YOUR ORDER FORM. Mail
or
fax
the order and this page to the Great Basin Cache Supply Office. The Great Basin
Cach
e
requires
the
use of Visa / MasterCard / Discover / Amex for all orders placed by federal
agencies,
private
individuals
, university/college bookstores,
and
military organizations ordering
from
the Part
2:
Publication
Catalog. Orders received from these groups without
the credit card
informati
on
will not
be
processed.
If you have any
questions
please call the Great Basin Cache Supply
Office
at
(208)387-5104. PLEASE NOTE: ORDERS BILLED TO A CREDIT CARD WILL NOT ALLOW FOR
“BACK
ORDERED” ITEMS. YOU WILL NEED TO REORDER IF AN ITEM IS OUT OF STO
CK.
Information collected from this form may be subject to the requirements of the Privacy Act (5 U.S.C. 552a). This form is
used solely as a method of payment for goods and/or services provided to federal agencies, businesses, and private
individuals by the Bureau of Land Management at the National Interagency Fire Center. The information collected will
be stored in a secure location with access limited to those employees designated as Collection Officers. Any
information that we collect may be subject to disclosure, but will be handled in accordance with the requirements of the
Privacy Act and the Freedom of Information Act to ensure the greatest protection of personal privacy in the face of any
required disclosure. Except as might be required by law, we do not share any information we receive with outside
parties.
DATE:
CARD HOLDER NAME (please
print)
ADD
RESS
CITY / STATE / ZIP CODE
TELEPHONE #
CREDIT CARD NUMBE
R
American Express (
)
DISCOVER
(
)
VISA (
)
MASTERCARD (
)
EXPIRATION DATE
(MO/YR)
CARD HOLDER SIGNATURE (REQUIRED)
Title 18 U.S.C. Section 1001, makes it a crime for any person
knowingly
and
willfully
to make to any
department
or age
ncy
of
the United States any false,
fictitious
or
fraudulent
statement or
representations
as to any matter within its
j
u
risdic
tion
.
For NIFC FINANCE USE ONLY NIFC 1372-2 (February 2006)
click to sign
signature
click to edit
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