Credit Card Checklist

Dear Client,
We confirm the purchase for Ref No: ..as discussed with you on././20..and would
be obliged if you would check the following details, sign the form, and fax or email back to us on 086 511 9816 / 011 452
9507 or order@flyerz.co.za so that we can process your payment.
Step 1 Personal Details:
Company Name: ....
Title:. Initials:First Name:
Surname:....ID Number:
Physical Address:

Postal Address:

.
Cell:..Home:
Work:..
Step 2 Payment Details:
Please debit my credit card (please tick the correct box)
VISA

Mastercard

Expiry Date/..

Card No.
Security No.

(last three numbers on the back)

Payment: Straight

Budget

12

24

36

months

AMOUNT

I authorise Flyerz.co.za to debit the above account for the purchase as stated.

Signature

Date