I ___________________________ (Cardmember Name) Hereby authorize

_________________________(Merchant Name) to charge my American Express Card an amount of Rs.__________________ for the Servies rendered.

Card number:     

Card expiry date:      __ __ / __ __ __ __ [MM/YYYY]

Billing address _____________________________________________________________________________

_________________________________________________________________________________________

________________________________________________________________________________________

City ___________________________________ Pin Code: _______________

Telephone: (      )____________________________ Mobile: ________________________

I understand that the Record of charges in respect of Services Recieved / Availed by me, submitted by Merchant Establishment as mentioned below to American Express Banking Corp. will neither bear my signature nor the imprint of the Card and I therefore undertake to unconditionally honor and pay without any demur and contentions, the charges as and when I am billed for the same by American Express Banking Corp.

Thanking you,

Yours sincerely,

(Signature as it appears on the American Express Card)

Name:   ________________________________________________________________

To be filled by Merchant Establishment

Merchant number __________________________________________

Merchant name ____________________________________________

Fax Number ____________________________________________

Contact Number ____________________________________________

Contact Person ____________________________________________

download form

 

Services International
25/8 Old Rajinder Nagar
New Delhi 110060, India,

I hereby authorize Services International to debit my Credit Card Account, details of which are:


Visa Card / Master Card (kindly tick the appropriate card type)

Name of the Cardholder : __________________________________________

Credit Card No : ___________________________________________________

Expiry Dat e:______/______ (MM/YY) (Should be valid for at least 6 months)

Amount : ____________

Issued by :___ __________________________________ (Name of the issuing bank)

Complete Address :_________________________________________________________________________
_________________________________________________________________________________________

Contact No: ____________________________________

I understand that all payments for services rendered/to be rendered are to be charged to my Credit card account and I undertake to unconditionally honor and pay the said charges as and when I am billed for the same by the aforementioned bank.

I agree to inform Services International in writing about the alternative payment option in the event that the above card is cancelled, substituted, or not renewed.

Signature of the Cardholder (As appearing on the Credit Card): _________________________________________________

Place : _____________________________

Date : ______________________________


Encl: Photocopy of the front & back side of the credit card duly signed by me


Services International: Option to International Credit Cardholders

As a convenience to our international customers, we now offer you a choice to be billed in your card billing currency or Indian Rupees when you pay with a Visa or MasterCard payment card. Please indicate your choice of transaction currency by checking the box below and signing, to confirm your option.

_______________________________________ (Signature) I would like my bill to be transacted in my card billing currency

_______________________________________ (Signature) I would like my bill to be transacted in Indian Rupees/billing to be in INR in case card billing currency is not supported for DCC

Your choice of transaction currency is final. The exchange rate for currency conversion will be determined on the order processing date. This service is offered by the merchant’s service provider. No additional fee or commission is applied.

download form