CREDIT CARD AUTHORISATION FORM
Please print out and fax or post us this form.
Payment Type: ; Visa ; MasterCard ; Bankcard
Card number: ____________________________
Expiry Date: ____/____
Name on Card: ______________________________________
Signature: ______________________________________
Date: ____/____
Cost of shoes $_______+ postage $______ (In Australian Dollars)
Total Payment amount: $________ (In Australian Dollars)
Name: ___________________________________________
Address: __________________________________________________________________
______________________________________________________________________________
Phone No ::_____________________________
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