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COSMIC PAGES CREDIT CARD AUTHORISATION FORM
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Date: ........../............../.............
Name _____________________________________________________
(Please print in block letters)
Telephone Number: _(_____)___________________________________
Payment type: Cheque / Money Order / Visa / Mastercard / Bankcard / Diners / Amex (please circle whichever applicable
Full Name on the card ________________________________________
Card No: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (16 digits) Exp. Date ____/____
GOODS ORDERED
_______________________________________________________
PRICE
__________________
incl. Post. $________
TOTAL $________
DELIVER TO:
___________________________________________________
Signature:.....................................................................................
Your Fax Number: ________________________________
POST TO:
COSMIC PAGES
338-340 King William Street
ADELAIDE
SOUTH AUSTRALIA 5000
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