creditcardfax

Safe Credit Card Payment

Some customers are unsure of using their Credit Cards over the Internet

To ensure safe Payment, PLEASE PRINT this Form - FILL IT IN and FAX DIRECT
to +(61) 08 9076 1888

Business Name:

Business Type:

1st Name: Surname:

Address:

Town:

State/Province:

Post/Zip Code:

Phone: Fax:

Country: Present email:
______________@________________

Payment Details: Please Circle Payment Method & Complete Details

Visa	MasterCard	Bankcard	Cheque	Money Order
Credit Card No:				Expiry Date:
Name on Card:				Comments:
Signed:
Product Details				Price
Please Fax to (+61) 08 9076 1888 Thankyou for using our service Please contact us if you have any enquiries or ideas to improve our services to YOU Privacy Statement: We respect your right to privacy. Any information that you supply will be held in strictest confidence and will not be made available to any other source				Total Price to debit

Some customers are unsure of using their Credit Cards over the Internet
To ensure safe Payment, PLEASE PRINT this Form - FILL IT IN and FAX DIRECT to +(61) 08 9076 1888
Business Name:	Business Type:
1st Name:	Surname:
Address:	Town:
State/Province:	Post/Zip Code:
Phone:	Fax:
Country:	Present email: ______________@________________