Charge my □ VISA  □ MASTER  □ U CARD  □ JCB  

 

  Order Date _________/____/____ (yy/mm/dd)

                                                                

  Credit Card Number_______________________                        Expiry Date ____/____

 

  Card Holder’s Signature_______________________________________________

  (as signed on the card)

 

  Amount  ____________________________

 

  Invoice to   _________________________________________________________

 

  Receiver’s Name ______________________      Tel No._______________________

 

  Receiver’s Address _____________________________________________________

 

  Special Instructions______________________________________________________

 

  ______________________________________________________________________