FAX Payment Form: Date: _________________________
| First Name_________________________ |
|
Phone __________________________ |
|
Fax ___________________________ |
|
Last Name________________________ |
| E-mail __________________________ |
|
Order No_________________________ |
|
Postal Address |
|
|
|
|
|
Delivery Address |
|
|
|
|
|
|
|
|
Goods Ordered / Our Reference
|
|
|
|
|
|
|
|
|
|
|
|
Amount Paid( Inc GST and Freight )
|
$ |
|
Credit Card Type |
|
|
|
|
|
Credit Card No
| |
| Expiry Date (mm/yy) / | |
|
Name of Card Holder as on Card ________________________________________ | |
|
Signature of Card Holder _________________________________________ | |