| Name: |
_________________________________________________ |
| |
|
| Address: |
_________________________________________________ |
| |
|
| City: |
_________________________________________________ |
| |
|
| State: |
_______________________
Zip code:______________ |
| |
|
| Telephone: |
_________________________________________________ |
| |
|
| Fax: |
_________________________________________________ |
| |
|
| e-mail: |
_________________________________________________ |
| |
| Credit
card: |
American
Express (*) MasterCard Visa |
| |
|
| Name
of cardholder: |
_________________________________________________ |
| |
|
| Card
number: |
_________________________________________________ |
| |
|
Expiration
date: |
Day |
________ |
Month |
_______ |
Year |
_________ |
|
| |
|
| Signature: |
_________________________________________________ |
| |
| (*) |
If
you are an AMEX card holder, write the code number located
on the upper right side of the account number:
. |
|
| |
| I owe
and agree to pay unconditionally, upon demand, the amount herein
specified, and any or all charges evolving from same, at the
time this bill is presented by the credit card company, or any
authorized representative. |
|
| |