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 ::_____________________________