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AMERICAN EXPRESS CARD (There will be an
additional charge of 3 %)
MAIL ORDER REQUEST FORM |
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I ___________________________ HereBy Authorize SERVICES INTERNATIONAL
(Cardmember Name)
to charge my card for the services rendered
Card Number _____________________________________________________
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Card Expiry Date _____________________________________________________
Billing Address _______________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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Home Telephone Number ________________________________________________ |
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Work Telephone Number ________________________________________________ |
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Mobile Telephone Number ________________________________________________ |
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| Present Address________________________________________________________ |
___________________________________________________________________________ |
___________________________________________________________________________ |
___________________________________________________________________________ |
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Amount of Charge(In Local Currency) _________________________________________
Amount of Charge(In Indian Currency) _________________________________________
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I understand that the Record of Charges - In respect of services received /availed-submitted by you to the Credit Card Signature nor the imprint of the card and i therefore undertake unconditionally honour and pay without any demur a mentioned above as when i am billed for the same. |
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Thanking you,
Yours sincerely,
(Signature as it appears on the Card)
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| Name : |
| Date : |
| To be filled by Merchant Establishment |
Merchent Number __________________________________________________________ |
Merchent Name ____________________________________________________ |
Fax Number __________________________________________________________ |
Contact Number __________________________________________________________ |
Contact Person __________________________________________________________ |
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