Credit Card Authorisation Form
Please print out and fax or post us this form.
Payment Type: ; Visa ; MasterCard 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 ::_____________________________
