| Credit Card Debit Authorisation |
| Company/Customer Name: ______________________________ |
| Phone: ________________________ |
| Fax: ________________________ |
| Email: ________________________ |
| Nature of Payment (Deposit, Invoice, Balance, etc): ______________________________ |
| Additional Information (If Any): |
Select Credit Card Type:
[ ] Visa.
[ ] Access.
[ ] Mastercard.
[ ] American Express.
CVV# __________ |
| Credit Card Number / ________ / _________ / _________ / _________ / |
| Iban / Swift Code /_________ /_________ /________-________ / |
| Card Holders Name: __________________________(As it appears on your card) |
| Credit Card Expiry Date: (MM/YYYY) _____________ |
| Amount to Debit From Credit Card (EURO) € __________ |
Card Holders Signature _______________________________
I have read and agree to the Terms & Conditions |
| Confidentiality guaranteed, no information is shared |
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